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THE 

Neurological  Practice  of  Medicine; 


A   Cursory    Course   of    Selected    Lectures 


IN 


Neurology,     Neuriatry,    Psychology    and     Psychiatry; 
Applicable  to  General  and   Special   Practice. 

WITH   177  ILLUSTRATIONS. 


AFTER    THE    AUTHOR'S    CLASS-ROOM    METHODS    AS    A 
TEACHER    OF    STUDENTS. 


DESIGNED    FOR   STUDENTS  AND   GENERAL    PRACTITIONERS   OF    MEDICINE 

AND    SURGERY. 


By  CHARLES  H.  HUGHES,  M.  D., 

President  of  the  Faculty  and  Professor  of   Neurology,   Psychiatry  and  Elec- 
trotherapy,  Barnes  Medical  College.      Former  Major  and  Surgeon-in- 
Chief    of    Schofield,    Winter,    Hickory   Street,  and    McDowell's 
College  Military  Hospitals,  Superintendent  Missouri  State 
Insane    Hospital,    Acting    and    Honorary    Member 
of    Many  Home  and    Foreign    Medical  and 
Scientific    Societies,     Etc.,     Etc. 

Member    Governing    Board    of    Centenary  Hospital,   Ex- Member    Board    of 
Health  and  Consultant  of   City  Hospital,   Insane  Hospital,   Etc. 

1903 


Digitized  by  the  Internet  Archive 

in  20TO\^ funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/neurologicalpracOOhugh 


.-I 


TABLE    OK    CONTENTS. 


TITLE   PAGE  -  _____  1 


COPYRIGHT 


2 


DEDICATION  _____  3 

INTRODUCTORY  _  _  -  -  4-9 

EDITOR'S   PREFACE  -  -  -  -        10-11 

CHAPTER   i  ------  -  12-22 

Preliminary  Essential  Definitions,  Etc.  Neuroanatomy,  Neu- 
rology, Neuriatry,  Psychology,  Psychiatry,  Neurophysiology, 
Neuropathology,  Neurotherapy,  Psychotherapy,  Psychopath- 
ology,  Alienist,  Psychiater,  Neuriater,  the  Neurone,  Nerve 
Center,  Etc.,  Etc. 

Chapter  ii  _______       23-35 

The  Neurone  and  the  Nerve  Cells;  Their  Composition  and 
Characteristics. 

CHAPTER  in  ------  -         36-42 

The  Neurone  and  the  Nerve  Centers,  Continued;  the  Neu- 
rone Conception  or  Theory,  Association  Neurones,  Projection 
Fibers,  Etc. 

CHAPTER  IV-  -  -  -  -  -  -         43-47 

The  Neurone  Continued;  Its  Efferent  Prolongation  or  Prolifera- 
tion. The  Axone,  Neuraxone,  Neurite  or  Axis  Cylinder  Pro- 
cess; the  Nerve  Cell  and  Its  Belongings.  Histological  Compo- 
sition of  Nerve  Centers.  The  Neurone  and  Its  Dendrites  or 
Afferent  Cell  Processes.     The  Neuroglia. 

CHAPTER  V  -  -  -  -  -  -'-         48-56 

Outline  Forms  and  Functions  of  Neurones.     Polar  and  Apolar, 

[i] 


Pace 
Bipolar  and  Multipolar  Neurones.     Neurone  and    Nerve   Cell; 
Synonymous    in    a    Broad    Sense.     Disease    Changes    in    the 
Neurones. 

CHAPTER  VI  ------  -         57-69 

The  Neurones  Grouped  into  Layers  or  Strata  of  the  Brain  Cor- 
tex;  Further  Consideration  ol  the  Neurones  and  of  the  Asso- 
ciated Fiber  System  of  the  Brain  and  of  the  Projection  System 
of  the  Brain  and  Spinal  Cord.  Functions  ot  Neuroglia  and 
Mesoglia. 

CHAPTER    VII  -  -  -  -  -  -  70-82 

Head  Heat  in  Brain  Disease,  Cerebral  Thermometry,  and  Ceph- 
alic Galvanization.     Their  Value  in  Diagnosis  and  Practice. 

CHAPTER  VIII  -  -  -  -  -  -         83-89 

The  Temperature  Sense,  Etc.,  and  Its  Alterations  in  Diagnosis. 

CHAPTER   IX  ------  -         90-100 

Extra-Neural  or  Adneural  Nervous  Disease.  Systematic  States 
Leading  to,  Proceeding  from  and  Blending  with  Nervous  Dis- 
ease; A\alaria,  Erythrocytes,  Thermasia,  Thermesthesia; 
Their  Effects  on  the  Neurones,  Etc. 

CHAPTER   X  ------  -  101-116 

Extra-Neural  or  Adneural  Nervous  Disease.  Chromatic  and 
Achromatic  Neurones,  Chromatolysis,  Thermal  Changes  in 
the  Neurones.  Brain  Neurones  as  Heat  Centers,  Adneural 
Heat  Changes  of  Neurones,  Marinesco's  and  Lugaro's 
Law  of  Morbid  Neurone  Change,  Reflex  Phenomena  and  the 
Neurones. 

CHAPTER  XI         --..---  -  117-136 

Instruments  and  Procedures  of  Precision  in  Diagnosis  and 
Practice. 

CHAPTER  XII       -  -  -  -  -  138-147 

Instruments  of  Precision  (Continued). 

CHAPTER  XIII      -  __,---         148-156 

Instruments  of  Precision  (Concluded).  The  Sphygraograph, 
the  Percuteur  and  Polygraph  in  Practice. 

CHAPTER  XIV     -  -  -  -  -  -  -         157-163 

Ascending  and  Descending  Degeneration.  Reaction  of  Degen- 
eration;   Waller's  Law;     Its  Diagnostic  Significance. 


Mi 

Page 
CHAPTER  XV      -  '  164-170 

The  Reaction  of  Degeneration  and  Its  Use  in  Diagnosis.     How 
to  Discover  It.     Applicable  Cases. 

CHAPTER  XVI     -  -  -  -  "  "  _  171-177 

How  the  Reaction  of  Degeneration  is  Diagnosticated. 

CHAPTER  XVII  ----""  178-182 

Another  View  of  the  Reaction  of  Degeneration. 

CHAPTER  XVIII  -----  ~         183-195 

The  Evolution  of  the  Neuraxis.    Nature's  Building  of  the  Brain 
and  Spinal  Cord. 

CHAPTER  XIX  ------  196-210 

The  Evolution  of  the  Brain  and  Spinal  Cord  or  Neuraxis  (Con- 
tinued). 

CHAPTER  XX      - '         211-225 

History  of  the  Evolution  of    the  Brain.     Some    Further   Facts 
Concerning  the  Brain. 

CHAPTER  XXI      -  -  -  "  "  "  '  226-241 

The    Brain's    Blood    Supply.     The   Intercranial  Circulation    in 
Its  Relation  to  Brain  Disease. 

CHAPTER  XXII  -  -  "     .  "  "         243-251 

Electricity  and  Electrical  Appliances. 

CHAPTER  XXIII  ------         252-265 

The  Dura;     Its  Sinuses  and  Diseases:     A  Cursory  Anatomical 
Demonstration. 

CHAPTER  XXIV  ------         266-282 

Cerebral  Embolism,  Thrombosis  and  Hemorrhage,  and  Some  of 
Their  Sequent  Brain  Diseases  Cursorily  Considered. 

CHAPTER  XXV  ------  283-300 

The  Anatomy  of  the  Spinal  Cord,  With  Brief  Reference  to  Its 
Morbid  States. 

CHAPTER  XXVI  ------         301-307 

Nerve  Centers  (Continued).      Psycho-Motor    Centers— Visual 
Apparatus  Centers— Other  Motor  Reflex  Centers. 

CHAPTER  XXVII  -  -  -  -  .    -         308-327 

The  Sensori-Motor  System  in  Diagnosis.     The  Reflexes. 


CHAPTER   XXVIII  .--...  328-344 

The  Cerebro-Spinal  Axis  or  Neuraxis  and  Its  Nerve  Centers. 
Ganglia.  Plexuses,  Neurones  and  Nerve  Centers.  Importance 
of  the  Pupil  and  other  Nerve  Centers  in  Diagnosis.  The  Basal 
and  Other  Ganglia.     The  Neuraxis  and  the  Neurone. 

CHAPTER  XXIX  -----         345-351 

The  Neuraxis  Again,  Diagnosticallv  Viewed.  A  Cursory  Dem- 
onstration of  Cranial  Nerves.  The  Columns  of  the  Spinal 
Cord  and  the  Nerves  that  go  to  and  from  It.  The  Cord  Seg- 
ments of  Impression  and  Influence.  Outline  of  the  Cerebral 
and  Spinal  Nerves  and  Nerve  Centers  and  Their  Relation  to 
Nervous  Disease. 

CHAPTER  XXX    -------         352-369 

Outline  of  the  Cerebral  and  Spinal  Nerves  and  Nerve  Centers 
and  Their  Relation  to  Nervous  Disease,  Etc.,  (Continued). 

CHAPTER  XXXI  ------         370-378 

The  Virile  or  Genesiac  Reflex  and  Its  Symptomatic  Value  in 
Practice. 

CHAPTER  XXXII  ------         379-391 

Aphasia  Defined  and  Located.  Aphasia  Physically  and  Psy- 
chically Considered.  Some  of  Its  Most  Essential  Phases  Dis- 
cussed. 

CHAPTER  XXXIII  ___--         392-399 

The  Medico-Legal  Aspects  of  Aphasia.  The  Case  of  Wm.  T. 
Bevin. 

CHAPTER  XXXIV  ------         400-406 

Psychological  Analysis  of  the  Bevin  Case  Concluded. 

CHAPTER  XXXV  ------  407-413 

The  Neural  and  Psycho-Neural  Aspects  of  Surgical  Practice. 
Lumbar  Puncture  as  an  Anaesthetic.  Tuffier's  Lumbar  Puncture 
in  Surgical  Diagnosis  and  Prognosis.  Lumbar  Puncture  and 
Neuro-  or  Cyto-Diagnosis.  Idiotrophic  Affinities  and  Reac- 
tions of  Neurones. 

CHAPTER  XXXVI  _-.---         414-417 

The  Nutrition  and  Conservation  of  the  Neurones,  or  Neuro- 
and  Psychotherapy  in  Surgery.  The  Psychiatric  Factor  in 
Surgery.  Psychical  Depression  and  Neuropathic  Diathesis. 
Post-Operative  Insanity. 


LECTURES   ON    NEUROLOGY   AND    NEU- 

RIATRY,   PSYCHOLOGY   AND 

PSYCHIATRY. 


AFTER    THE    METHODS    OF    THE    CLASS-ROOM,   TO    THE    AUTHOR'S 
STUDENTS,   AND   DESIGNED  ALSO   FOR  GENERAL  PRAC- 
TITIONERS OF  MEDICINE  AND  SURGERY. 


By  C.   H.   HUGHES.   M.   D,, 

Member  American   Medico-Psychological  Association,  Honorary  Member  of 
New  York  Medico-Legal  Society,  British  Medico-Psychological  Associa- 
tion, Foreign  Member  of  Russian  Society  of  Neurology  and  Psychiatry, 
Honorary  Fellow  of  Chicago  Academy  of  Medicine,  Ex-Member 
of  Judicial    Council  and  of   the  Executive  Board  A.  M.  A., 
Ex-Supt.  and  Physician-in-Chief    Mo.  State    Hospital 
for  the  Insane,  Ex-Pres.  Miss.  Val.  Med.  Ass'n, 
American    Med.  Editors'    Ass'n,  and   Ex-Pres. 
of  Section  on  Neurology  American  Med.  Ass'n 
and   Pan-American  Medt  Congress,  Ex- 
vice-Pres.    Sections    Physiology  and 
Psychiatry,  Med.  Congress,  1876, 
Pres.  of   Faculty    and    Prof,  of 
Neurology,   Psychiatry    and 
Electro  -  Therapy  Barnes 
Medical  College,  etc., 
etc.,  St.  Louis. 


EDITED  BY  PROF.   MARC   RAY  HUGHES,   M.   D., 
BARNES  MEDICAL  COLLEGE, 
ST.    LOUIS. 


Press  of  HUGHES  &  CO.,  418  N.  Third  Street,  St.  Louis. 


COPYRIGHTED   1902 

BY 

C.   H.    HUGHES. 


.     DEDICATION. 

TO  MY  PAST  AND  PRESENT  STUDENTS  NOW  LIVING 
IN  THE  SEVERAL  STATES  OF  THIS  AMERICAN  UNION 
AND  IN  COUNTRIES  ABROAD  who  have  stood  about 
me  at  the  anatomical  table  or  sat  around  or  before  me  in 
the  amphitheater  of  the  three  colleges  in  which  1  have 
lectured,  the  Barnes,  the  Marion-Sims  and  the  St.  Louis, 
now  the  Medical  Department  of  Washington  University, 
this  book,  containing  the  substance  of  a  selected  part  of  my 
lectures  on  the  great  themes  of  neurology  and  neuriatry, 
is  fraternally  and  cordially  dedicated. 

Like  the  diploma  with  which  you  went  out  from 
college  or  hope  to  take  out  as  your  shield  in  the  battle  of 
your  professional  life,  these  lectures  represent  the  com- 
mencement of  your  medical  career,  in  its  neurological  aspects 
and  the  neuriatric  search  light,  your  friend  and  servitor 
has    endeavored  to  throw  on  your  pathway. 

If   by  this  light  your  way  has  been  made  easier  to  walk 

or  shall    be   further  illumined,  the  pleasure    of  knowing  that 

your  welfare  will  have  been  thus  promoted,  will  prove  ample 

reward  for  the  author's  pains  in  preparing  these  lectures  in 

book  form,  in  the  midst  of  a  busy  professional  life. 

:'If  he  hath  lent  strength  to  the  weak" 

***** 
"Or  let  in  a  ray  of  sunshine" 

that  has  made  any  dark  and  crooked  path  in  neurology  or  neu- 
riatry bright  and  straight  to  you,  his  labor  has  not  been  in 
vain. 

THE  AUTHOR. 
[3]. 


INTRODUCTORY. 

This  book  aims  to  lift  students  along  their  arduous  way, 
over  the  neurological  obstacles  in  their  path,  especially  those 
who  have  been  under  the  author's  instruction. 

It  does  not  aim  to  go  all  the  way  or  point  out  all 
the  paths,  but  some  of  the  best  neurological  roads  for  the 
general  practitioner  to  follow. 

It  is  hoped,  that  of  the  many  who  have  heard  the 
author's  lectures,  the  most  of  them  will  look  over  these  pages 
with  pleasure  and  profitable  retrospective  memory,  as  the 
author  does,  while  others  yet  to  hear  or  read  his  teachings, 
will  find  them  instructive  and  labor-saving. 

Among  master  minds  in  medicine,  neurology  and  the 
neurological  aspects  of  disease,  and  neuriatry  and  psychia- 
try, and  the  management  of  the  nervous  system  and  mind 
in  the  conduct  and  cure  of  disease  in  general,  are  justly 
claiming  more  attention  than  in  the  past. 

Through  anatomical,  physiological,  chemical,  bacteriolog- 
ical, cytological  and  haematological  discovery,  the  views  of 
Cullen  and  his  contemporaries  are  receiving,  of  late,  more 
neuro-physiological  amplification  and  illumination  than  in 
the  days  of  the  great  nosologist  and  clinician  of  the  closing 
eighteenth  and  beginning  nineteenth  centuries. 

We    are    approaching    and     standing    upon    surer    and 

sounder  clinical  ground  and,  as  we   see  with  more  scientific 

precision,  we  begin  to  discover,    notwithstanding   the    great 

value   of    other   departments   of   medico-scientific    research, 

[4] 


the  supreme  importance  of  a  knowledge  of  the  nervous  sys- 
tem in  the  practice  of  medicine. 

As  I  have  before  predicted,*  Neurology  is  yet  destined 
to  reign  paramount  in  clinical  medical  thought,  notwith- 
standing the  conceded  just  importance  of  every  depart- 
ment of  practical  medicine. 

The  successful  treatment  of  disease  consists  in  the 
proper  management  of  the  entire  man.  With  certain  local 
exceptions  the  problem  is  a  neurohaemic  question!  and  the 
tone  and  quality  and  conditions  of  the  nervous  system  are 
evermore  uppermost  in  the  study  and  treatment  of  disease, 
whether  we  aspire  to  be  an  especially  qualified  neurologist 
or  a  practitioner  over  other  areas  of  the  human  anatomy, 
but  with  an  adequate  knowledge  of  its  important  neural  rela- 
tions. 

Those  who  have  heard  the  author  in  his  lectures  touch 
on  neurology  in  general,  know  that  he  believes  that  the 
field  of  neurology  must  widen  in  practice  till  it  ceases  to 
be  a  special  department  of  medicine,  save  in  its  essential 
manipulations,  as  many  other  fields  of  medical  work  now 
regarded  as  specialties  must  eventually  become. 

The  practitioner  of  medicine  will  become  the  clinical 
neurologist  in  ordinary  practice,  while  extremely  expert 
neurologists  will  become  consulting  neurologists  and  neu- 
riatrists  to  the  profession,  advisers  and  coadjutors  in  the 
neural  aspects  of  ordinary  disease  and  masters  in  applied 
neurotherapy  in  such  cases  as  the  general  practitioner  can 
not  have  the  instruments  or  manual  dexterity  or  the  time  or 
the  clinical  experience  to  properly  treat. 

The  practice  of  medicine  has  become  so  great  a  field  of 
human  endeavor  that  it    is  impossible    for    any  one  man  to 

♦Dedication  of  Alienist  and  Neurologist,  1880. 
tAddress  In  Medicine  Amer.  Med.  Ass'n,  San  Francisco,  1887. 


operate  over  its  entire  area.  He  may  think  it  over,  but  to 
work  all  over  it,  is  now  impossible  to  human  capability. 
\\\  haw  reached  the  epoch  of  division  and  exchange  of  work. 
Whether  or  not  you  who  read  may  coincide  with  me, 
this  fact  you,  I  believe,  will  always  find  to  be  a  truth  in 
practice;  the  nervous  system  understood  up  to  date  in  its 
structure,  functions  and  management,  will  prove  a  constant 
source  of  intellectual  pleasure  and  profit  in  the  understand- 
ing and  treatment  of  all  disease.  To  be  a  good  neurologist, 
to  express  it  in  phrase  Chesterfieldian,  is  to  be  the  "high- 
est style"  of  physician. 

These  chapters,  as  you  who  have  heard  my  lectures 
will  discern,  are  not  complete,  even  as  they  were  delivered. 
They  omit  some  and  include  other  matters  touched  upon  in  the 
amphitheater  and  embrace  also  some  subjects  more  elaborately 
referred  to  in  the  class-room  and  clinic  and  some  matters  less 
extensively  mentioned,  as  in  the  cerebro- neural  demonstra 
tions.  It  is  only  as  milepost  helps  and  signboard  guides  to 
your  neurological  journey,  that  this  matter  is  put  in  book 
form.  You  have  become  accustomed  to  my  ways  of  pre- 
senting matters  of  moment  to  you  in  neurology.  It  will  help 
you  some,  like  the  repetitions  of  phonography,  to  have  this 
book  with  you  when  you  wish  to  review  your  studies  and 
refresh  your  minds  now  jaded  with  the  multifarious  demands 
of  college  work,  after  more  leisure  shall  have  come  to  you 
in  the  vacation  interim  of  the  college  curriculum  or  while 
in  practice.  Besides  this,  the  book,  I  hope,  will  keep 
us  closer  together  in  that  cordial,  friendly  relationship  which 
is  now  and  has  ever  been  so  pleasant  to  us  as  teacher 
and  learner.  And  1  have  myself  been  a  learner,  for  he  who 
constantly  teaches  an  intelligent  body  of  young  gentlemen, 
continually  learns  more  and  more  as  he  teaches.  There  is 
an  inspiration  to  further  study  and    research    in  an    earnest 


knowledge  seeking  audience  of  young  industrious  students 
energetically  determined,  as  you  are  or  have  been,  to 
acquire  the  highest  of  all  knowledge,  neurology,  embrac- 
ing as  it  does,  psychology  and  psychiatry,  in  the  study  and 
understanding  of  man. 

Knowing  that  you  are  to  benefit  or  harm  the  world 
by  what  you  acquire  or  fail  to  acquire  from  my  teaching,  1 
have  felt  the  grave  responsibility.  Many  a  time  after  a  lecture 
or  demonstration,  realizing  that  I  did  not  come  up  to  my  ideal 
of  how  the  knowledge  you  needed  and  how  much  of  it  should 
have  been  imparted,  I  have  gone  to  the  fountain  sources  in 
the  late  hours  of  midnight  or  early  hours  of  morning  for  more 
light,  in  order  that  you  might  not  be  deprived  of  the  neces- 
sities of  your  future  professional  success,  in  ministering  to 
the  welfare  of  those  who  are  to  trust  you  with  their 
health  and  their  lives. 

So,  though  you  may  not  have  thought  it  at  the  time, 
you  have  spurred  me  on.  I  have  studied  with  you.  We 
have  together,  though  separated,  burnt  the  midnight  oil  or 
early  morning  lamp,  seeking  for  more  light,  as  Ajax  prayed, 
to  win  the  conquest  of  Neurological  Truth  in  which  you  and 
1  alike  have  been  interested  for  the  good  of  our  fellow  man. 

1  have  delved  in  higher  ledges  of  the  mine  of  neurologic 
truth  than  you,  but  my  chief  inspiration  has  been  to  cast  the 
product  of  my  delving  into  your  level  in  good  "pay  dirt" 
from  which  you  might  "pan  out"  the  precious  metal  of 
neurological  fact  to  be  worked  by  you  into  instrumentalities 
of  neuriatric  relief  for  man  and  woman  in  your  respective 
spheres  of  influence  in  the  world. 

1  have  reached  up  to  the  ledges  where  Obersteiner, 
Obermier,  Wundt,  Fritz,  Hitzig,  Heubner,  Hugenin, 
Oppenheim  and  his  master  Carl  Westphal,  Edinger, 
Hirst,    Nothnagel,  Mendel,  Mickel,  Meynert,  Morison,   Ross, 


8 

Fournier,  Bastian,  Ireland,  Drummond,  Clouston,  that  English 
Coryphaeus  Gowers,  the  brilliant  Charcot,  Fere,  and  others 
of  his  pupils,  and  the  talented  Vangehuchten,  have  worked 
and  I  have  handed  samples  of  their  work  down  to  you. 
1  have  done  the  same  with  the  researches  of  our  own 
geniuses  in  Neurology,  Spitzka,  Hamilton,  Webber,  Shat- 
tuck,  Church,  Chaddock,  Pearce,  Petersen,  Putnam,  Dana, 
Fisher,  Kiernan,  Mills,  Sachs,  Moyer,  Wier  Mitchell,  Cle- 
venger,  Dercum,  Knapp,  Lloyd,  Mann,  Starr,  Shaw,  Wood, 
the  plates  and  sections  of  Fuller, Flower,  and  the  indispensable 
Quain's  Anatomy,  Jacobs'  beautiful  pictures  of  anatomical 
art  and  the  contributions  of  the  lamented  Seguin,  Amidon, 
Gray  and  Hammond  and  the  promising  but  prematurely  cut  off 
Shaw,  Mink  and  Hazard  of  St.  Louis.  I  have  sometimes  found 
a  jewel  in  the  work  of  Trouseau  and  of  Watson,  those  medical 
Adisonian  thought  painters,  who  wrought  medical  observation 
into  captivating  and  true  speech  center  work,  before  ever  1 
was  brought  forth  or  dreamed  of  instructing  a  class  of  hungry 
ante  partem  Doctors  in  the  entrancing  mysteries  of  neurol- 
ogy. 1  have  traveled  far  and  long  into  the  fields  of  our 
science  and  picked  a  jewel  here  and  there,  burnished,  or  in 
the  rough,  and  some  of  them,  by  no  means  all,  1  have  given 
to  you  as  generously  as  they  have  been  freely  given  to  me, 
hopeful  of  their  helping  you  as  they  have  aided  me. 

These  lectures  aim  to  be  up  to  date  so  far  as  they  go. 

In  some  respects  they  are  a  little  advanced,    especially 
as  regards  the  reflexes,  over  current  text- books. 

They  make  no  pretensions  to  completeness. 

Their    aim    is    clearer   elucidation     of    already    traveled 
roads  in  practical  neurology. 

No    single    volume    could    compass    the    entire  field  of 
neurology,  even  exclusive  of  neuriatry  and  psychiatry. 

No  author  should  attempt  it  or  could  compass  the  whole 


9 

field  for  the  general  practitioner  or  even  for  college  students, 
in  one  volume. 

There  are  no  entirely  original  lectures  in  any  depart- 
ment of  medicine  in  these  days  of  community  of  interest 
and  free  research  in  our  noble  profession,  and  it  is 
noble  because  it  is  a  fraternity  of  mutual  endeavorers  for 
the  welfare  of  the  world.  Each  takes  what  his  fellow 
produces  and  adds  what  he  can  in  turn  to  the  common 
store  for  the  next  one  to  use  for  further  discovery  and 
more  extended  utility.  Methods  of  presentation  must 
therefore  naturally  be  more  original  than  the  materials 
of  any  modern  book  on  Neurology,  not  excepting  the  one 
I    now    offer  you. 

I  give  thanks  to  my  worthy  sons,  Doctor  Mark  Ray 
Hughes,  now  adjunct  to  my  chair,  and  to  Henry  L.  Hughes, 
for  valuable  aid  in  editing  and  in  revising  proofs,  etc. 

C.   H.   HUGHES. 
3860  West  Pine  Boulevard, 

St.  Louis. 


EDITOR'S  PREFACE. 

This  book,  as  the  advanced  reader  will  see,  is  intended 
to  cover  some  ground  not  quite  so  minutely  covered  in  my 
father's,  Professor  Charles  H.  Hughes'  regular  lectures,  and 
other  ground  more  briefly  than  when  delivered  before  the  class. 

The  aim  has  been,  as  1  have  it  from  the  author,  to  be 
helpful,  suggestive,  plain,  clear,  practicable,  retrospective 
and  not  too  technically  scientific  for  the  undergraduate  nor 
yet  uninteresting  for  the  post-graduate.  The  author's  de- 
sign has  been  to  present  a  familiar  series  of  talks  like  a 
book  that  has  once  been  gone  over  and  thumbed  and 
marked  by  his  classes,  '  making  things  already  known  to 
them  a  little  better  known  and  more  clearly  recalling  matters 
perhaps  but  partly  remembered  in  the  course. 

Where  repetitions  occur,  they  have  not  been  entirely 
unintentional,  but  have  been  permitted  to  remain  in  order 
that  the  impression  of  the  facts  may  be  fixed  in  the  minds 
of  the  students.  Hence  the  familiar  style  of  the  lecture 
room  appears  in  the  chapters  and  some  sentences  perhaps 
not  severely  appropriate  to  an  exclusively  scientific  book. 

The  author  pleads  consideration  of  his  busy  professional 
life  in  extenuation  of  the  many  faults  of  this  hastily  pre- 
pared volume,  especially  of  facts  of  omission  and  undue 
prolixity  of  diction,  as  dictated  to  the  editor. 

He  also  hopes  his  good  purpose  of  serving  the  needs 
of  the  medical  student  in  neurology  will  contribute  to  secure 
generously  charitable  judgment  on  the  book's  defects. 

The  editor's  part  of    this  work  has  consisted  mainly   in 

[10] 


11 

shaping,  it  for  publication.  All  of  the  chapters  have  been 
transcribed  essentially  as  dictated  except  the  chapter  on  the 
Psychological  Consideration  of  the  Penitentes,  of  which  the 
editor  is  the  sole  author.  For  this  he  invokes  the  generous 
indulgence  of  the  critical  reader. 

MARC   RAY   HUGHES,   M.   D., 
Adjunct    Professor    of    Neurology,    Psychiatry    and 
Electro-Therapy,   Barnes  Medical  College. 
3857  Olive  Street, 

St.  Louis. 


CHAPTER    I. 

PRELIMINARY  ESSENTIAL   DEFINITIONS,  ETC.      NEUROANATOMY,  NEUROL- 
OGY,  NEURIATRY,    PSYCHOLOGY,  PSYCHIATRY,  NEUROPHYSIOLOGY, 
NEUROPATHOLOGY,     NEUROTHERAPY,     PSYCHOTHERAPY, 
PSYCHOPATHOLOGY,     ALIENIST,     PSYCHIATER, 
NEURIATER,     THE     NEURONE,     NERVE 
CENTER,     ETC.,     ETC. 


You  cannot  advance  satisfactorily  in  the  study  of 
neurology,  which  comprehensively  embraces  neuroanatomy, 
neurophysiology,  neuropathology,  neurochemistry,  neuro- 
diagnosis,  psychology,  psychiatry,  etc.,  without  clearly 
comprehending  at  least  the  terms  named  in  this  chapter 
which  we  will  define  before  proceeding  further.  Neuro- 
anatomy is  nerve  anatomy,  as  its  derivation  implies, 
v€vpovt  a  nerve  and  TSfivav,  to  cut.  avarofx-rj,  dissection, 
dra-re/Aveiv,  of  or  pertaining  to  the  dissection  of  the  nerve 
tissue.  For  example,  veupov}  nerve  and  7ru#os,  disease, 
suffering,  neuropathology,  the  pathology  of  the  nerves, 
relating  to  nervous  system  or  nerve  centers,  etc.  Neurop- 
athy, disease  of  the  whole  or  any  part  of  the  nervous 
centers;  a  condition  of  general  or  local  nervous  disease. 
A  good  example  of  a  general  nervous  disease  or  disease 
of  the  general  nervous  system  is,  neurasthenia,  a 
condition  of  general  nervous  debility  dependent  on  general 
functional  neuratrophia  or  deficient  nerve  center  nutri- 
tion, with  often  an  inherent  constitutional  predisposition 
to  become  nervously  weak,  and  with,  consequently,  functional 

[12] 


13 

weakness  and  instability  or  unsteadiness  of  the  nervous 
system;  a  general  functional  disease  of  the  nervous 
system.  (vevpov,  a  nerve,  «,  privative  or  minus — and 
flews,  strength.)  Another  general  nervous  functional 
disease  is  hysteria,  which  is  a  very  nervous  condition, 
formerly  attributed  to  the  influence  of  the  womb,  though 
men  may  have  it.  The  influence  of  the  womb's  dis- 
eases, the  weakening  effects  of  its  functions  when  acting 
morbidly  and  of  exhausting  nursing,  woman's  indoor  rou- 
tine, sedentary  and  monotonous  life,  etc.,  the  recurring 
catamenia  and  its  stoppage  at  the  change  of  life,  or  climac- 
teric as  it  is  called,  though  the  life  is  not  changed  except 
to  go  on  to  another  stage  in  its  evolution  till  the  decadence 
of.  age  appears,  contribute  to  bring  about  states  of  nerve 
strain  and  exhaustion  which  give  the  preponderance  of 
hysteria,  neurasthenia  and  climacteric  nervous  states  to  the 
female  sex  in  mankind.  Great  brain  and  nerve-strain  at 
the  climacteric  and  senile  epochs  and  from  brain  overwork 
or  worry  tend  to  cause  nervous  break-down  and  grave 
nervous  diseases. 

Consult  the  derivations  in  your  medical  and  unabridged 
general  dictionaries  and  familiarize  yourselves  with  the  deriv- 
ative terms  wherever  you  can  find  them,  since  one  term  well 
understood  in  its  derivation  or  derivations  will  often  give 
you  signal  aid  in  the  understanding  of  many  other  medical 
definitions,  especially  compound  words,  and  thus  lighten  the 
labor  of  study  and  give  a  philological  zest  to  it.  Thus  you 
have  already  discovered  that  the  radical  word  neuron,  per- 
tains to  nerve,  nerve  cell  or  center,  and  it  is  embraced  in 
nearly  all  the  words  we  have  thus  far  mentioned,  and  plays 
a  great  part  in  medical  nomenclature. 

Other  specially  important  derivations  with  which  you 
should    become   familiar   are  pathos   (^mAos),  disease,  thenos 


14 

(flevos),  strength,  and  aesthesias,  (<ua0»/<ns)  sensibility,  and 
itis't  Latin  for  inflammation,  wherever  you  may  find  it  in  your 
studies.  You  will  encounter  the  words  neuropathy,  nerve 
disease,  and  psychopathy,  mental  disease,  neuritis,  nerve  in- 
flammation', phrenitis  or  cerebritis,  delirious  brain  or  cerebral 
disease,  neurasthenia  or  nervous  debility,  hyperesthesia 
or  increased  general  sensibility,  anaesthesia  or  absence  of 
sensibility,  hypoaesthesia,  lessened  general  sensibility,  ther- 
moaesthesia  or  sensibility  to  heat,  hypo  and  hyper  aesthe- 
sia  meaning  minus  or  plus  heat  sensitiveness,  hypoalgesia 
and  hyperalgesia  signifying  minus  or  plus  sensibility  to 
pain  below  or  above  the  normal  and  so  on. 

Look  up  these  terms  and  their  derivations  often  in  your 
dictionaries  (I  speak  to  the  juniors  especially  now),  and  we 
shall  get  along  swimmingly  for  awhile.  Do  not  be  offended 
at  my  assuming  that  some  of  you  may  not  know  all  these 
derivations  and  definitions.  No  harm  will  be  done  if  I  tell 
you  something  that  you  already  know,  but  great  harm  to  your 
progress  may  be  done  if  I  omit  making  your  pathway  as 
plain  and  easy  to  travel  by  these  timely  suggestions,  as  1 
can.  It  is  my  duty  to  clear  the  way  for  you  as  much  as 
possible.  I  would  make  it  plainer  and  easier  if  1  could,  but 
I  do  not  "know  it  all"  myself — not  so  much  as  some  of 
the  seniors,  perhaps,  for  seniors  know  very  much;  they  have 
caught  on  ahead  of  you,  you  know.  But  since  our  time 
of  study  together  is  so  brief,  if  I  am  as  explicit  as  I  can  be 
1  may  be  able  to  impart  to  you  most  of  what  I  know  before 
the  time  shall  arrive  for  your  final  examination.  1  will  do  it 
if  1  can  and  if  you  will  give  me  your  attention.  You  will 
not  be  examined  beyond  what  you  may  hear  or  see  in  these 
lectures  and  demonstrations. 

There  is  another  and  more  special  meaning  of  the  term 
neuron,  which  some    neurologists,  especially    that    American 


15 

neuroanatomical  investigator,  Lewellys  F.  Barker,*  As- 
sociate Professor  of  Anatomy  and  Resident  Pathologist  of 
the  Johns  Hopkins  University  and  Hospital,  now  calls  neurone 
to  distinguish  it  from  the  general  term  expressed  in  the 
original  Greek  root,  and  which,  as  I  have  said,  signifies  nerve 
or  nervous.  The  term  neurone  or  neuron  has  come  into  use 
since  Golgi,of  Pavia,the  great  Italian  cerebro-anatomist,  gave 
to  the  scientific  world  about  two  decades  ago,  his  remark- 
able studies  of  the  fine  anatomy  of  the  brain,  which  you 
may  find,  after  you  get  further  advanced  in  the  study  of  the 
nervous  system  and  acquire  that  insatiable  thirst  for  deeper 
knowledge  which  invariably  comes  to  the  enthusiastic 
student  of  neurology,  in  back  numbers  of  the  Alienist 
and  Neurologist  (1883)  which  was  the  first  and  only 
English  or  American  journal  of  that  day  to  place  before 
the  English-speaking  neurological  reader  the  advanced  work 
of  this  distinguished  savant  in  the  field  of  cerebral  discovery. 
Golgi's  lucid  findings  in  the  minute  anatomy  of  the  brain 
led  to  another  remarkable  epoch-making  discovery  in  neuro- 
anatomy, the  naming,  finding  and  defining  of  the  neurone 
and  its  processes  by  those  eminent  micro-neuroanatomists  and 
neurophysiologists,  Ramon  y  Cajal,  His  and  Schafer.  They, 
with  Nissl,  Vangehuchten,  Waldeyer,  Harris,  Held,  Forel, 
our  distinguished  Barker,  Hoch,  and  many  others  (more 
than  I  can  mention)  have  added  so  much  new  light  on  the 
neurone  and  its  relations  to  the  rest  of  the  nervous  system, 
that  you,  will  some  day  burn  with  desire  to  know  them  and 
their  great  work  and  to  know  the  work  of  many  others 
among   foreign    and    American  authors. 

As  the  time  passes,  during  this  course,  you  will  become 
familiar  with  other  great  names  in  neurology  than  those  1 
have  mentioned  and    learn    a    little    of    their   contributions, 


*The  Nervous  System  and  its  Constituent  Neurones,  New  York,  1S99. 


16 

but  with  whose  entire  work  you  will  not  find  time  to 
become  thoroughly  acquainted  during  this  session  or 
even  during  the  time  you  are  in  college.  Should  you 
find  opportunity,  however,  in  connection  with  our  present 
theme,  the  neurone,  either  now  or  during  your  vacation, 
you  can  read  with  profit  the  history  of  "The  Development  of 
the  Neurone  Concept,  the  Neurone  as  a  Unit,  and  the  Histo- 
genic  Relations  of  the  Neurone"  in  the  first  five  sections  of 
Barker's  great  work  to  which  1  have  already  referred,  making 
over  three  hundred  pages  of  solid  reading,  every  line  in- 
structive, in  this  more  than  one  thousand  page  volume  of 
neurological  fact  and  concept.  Great  work  and  great  names 
are  of  record  there,  besides  those  already  referred  to; 
Von  Gudden,  Von  Lenhossek,  Flesh,  Flatau,  Sandovsky, 
Biedl,  Bernheimer,  Marchi,  Berkley,  Marina.  Names  whose 
work  will  endure  after  we  shall  have  passed  away;  names 
that  will  abide  with  that  of  the  distinguished  author  who 
records  their  work,  for  Time  to  place  on  pages  of  im- 
mortal fame. 

THE    NEURONE    DEFINED. 

The  term  neurone  has  largely  supplanted  the  term 
nerve  cell,  or  ganglion  cell  of  the  older,  but  yet  quite  recent, 
neurological  nomenclature.  A  neurone,  or  as  it  is  still 
sometimes  called  a  neuron  in  the  neurocytological  nomen- 
clature and  cytology  or  cell  study  of  the  present  time, 
is  a  nerve  unit.  This  nerve  unit  includes  the  nerve  cell 
as  yet  described  in  most  of  your  anatomies,  its  processes, 
collaterals,  and  terminations.  For  all  practicable  purposes 
you  may  still  consider  it  a  cell,  a  nerve  cell,  {vtvpo\>-\- 
KVT05)  with  the  exception  that  it  is  not  a  network  of 
nerves  in  the  older  sense,  sending  out  prolongations  that 
blend  and  intertwine  with  contiguous  nerves,  but  a  nerve 
mesh,  or    neuropilem   {vtvpomXep.)    distinct    and    disconnected 


17 

but  capable  of  communicating  its  influence  by  contact,  as 
one  student  in  the  class  may  impress  another  by  close  or 
remote  contact  without  grabbing  him  by  the  throat  or  in- 
tertwining his  fingers  in  his  hair;  or  as  bricks  standing  in  a 
row.  Start  one  and  they  fall  one  after  another.  While  the 
old  nerve  net  of  Gerlach  is  yet  described  in  some  of  the 
books  you  have  but  lately  studied,  and  the  nerve  mesh  has 
taken  its  place,  the  ganglion  cell,  with  its  axis  cylinder  pro- 
cess, will  still  interest  you  as  a  fact  in  neurology,  only 
differently  and  a  little  better  understood  as  a  nerve  unit. 

The  neurone  has  dendrites;  cellulipetal  or  centripetal, 
the  equivalent  of  afferent  prolongations,  and  cellulifugal  or 
centrifugal  or  efferent  processes  or  neuraxons,  conducting  in- 
fluences away  from  the  cell  body.  With  reference  to  the 
center  of  the  neurone,  therefore,  the  dendrite  corresponds 
in  function  to  the  afferent  nerve  {ad  and  ferre,  to  carry  to) 
of  the  spinal  cord,  while  the  axone  or  neuraxone  corresponds 
to  the  efferent  {ex  and  ferre,  to  carry  from  or  eo,  1  go  forth). 
The  dendrites  receive,  and  the  axones  carry,  impression 
to  and  impulses  from,  the  center,  i.  e.,  to  and  from  the 
neurone  or  nerve  center  cell. 

There  are  some  exceptions  to  this  law,  as  in  those 
dendrites  from  which  an  axone  occasionally  takes  its  origin. 
An  example  may  be  found  in  the  retina,  but  you  need  not 
concern  yourselves  about  this  just  now;  you  will  not  be  asked 
about  these  exceptions  as  they  may  be  found  in  the  amac- 
rine  cells  of  the  retina,  etc.  The  rule  is  general,  but  not 
universal.  Barker  would  leave  the  question  open,  but  some 
questions  about  which  savants  may  wrangle  must  be  closed 
to  teachers  and  tyros  as  we  approach  the  close  of  this  lec- 
ture. 

Here  again  you  may  for  next  summer's  diversion,  after 
this  course  is  over,  take  with  you  the  books  of  the  neuro- 
physiological  masters    when    you  go  fishing,  or  retire  to  the 


18 

shade  of  the  trees  to  read  and  study  out  this  intricate  sub- 
ject between  nibbles  and  bites  on  your  hook,  for  one  of 
the  great  masters  to  whom  I  have  already  referred 
has  said  that  "at  present  we  are  well  acquainted  with  the 
evidence  of  the  passage  of  impulses  in  neurones  in  one 
direction  only,  does  not  exclude  the  possibility  that  we  may 
at  some  later  time  become  cognizant  of  the  facts  which  may 
demonstrate  the  conduction  of  impulses  of  some  sort  in  the 
opposite  direction,  especially  as  physiological  experiment  has 
shown  that  impulses  artificially  exerted  in  nerve  fibers  travel 
in  both  directions  from  the  point  of  stimulation."  (Barker, 
p.  274,  ed.  1899).  Here  then,  is  a  chance  for  you  to 
become  famous  while  you  fish,  by  working  out  the  unsolved 
problems  of  nerve  conduction,  vicarious,  alternate  or  sub- 
stitutive nerve  function,  etc.  The  vagus  nerve  appears  to 
have  both  afferent  and  efferent  function.  You  may  yet  be 
able  to  demonstrate  that  the  first  or  incoming,  and  the  second 
or  outgoing,  impressions  go  over  the  same  nerve  strands. 
If  you  do  your  fame  will  be  made. 

Neuraxon  or  neurite  means  the  axis  cylinder  pro- 
cess of  a  neurone,  the  principal  projecting  part  of  the 
neurone.  Schafer  also  called  it  a  neurone.  He  gave  the 
name  dendron  or  dendrite  (SevSpoi',  a  tree)  to  the  shorter 
protoplasmic  branchings  or  prolongations  or  processes  of  the 
neurons.  He  called  the  dendron,  a  dendrite.  Neuraxons 
vary  in  length  from  a  millimeter  or  less  to  many  centimeters. 
The  largest  neuraxons  are  in  the  pyramidal  tract,  measuring 
nearly  a  hundred  centimeters.  If  you  have  time  between 
the  lectures  or  during  your  vacation  you  may  consult  with 
signal  profit  the  first  chapter  of  Mills*  on  the  subject  and 
more  recent  American  authors.  You  will  see  in  the  very 
beginning  of    his  book,  on    the  first  page,  a  cut  taken  from 

*The  Nervous  System  and  its  Diseases  by  Chas.  K.  Mills,  Lippincott  &  Co.,  Philadel- 
phia and  London. 


19 

Quain's  Anatomy  and  to  be  found  in  some  other  anatomies 
and  neurological  treatises  to  which  I  shall  often  refer  and  which 
I  shall  several  times  draw  on  the  blackboard  during  this  course 
of  lectures,  as  I  do  now,  with  various  modifications.  I  am  ac- 
customed from  previous  and  consequent  automatic  habit  to  refer 
to  the  cerebro-spinal  or  encephalo-spinal  axis,  but  I  do  not  so 
often  use  the  newer  and  shorter  term  neuraxis.  The  term 
neuraxis  does  not  locate  itself  with  the  defined  expressiveness 
(though  it  is  shorter)  of  cerebro  or  encephalo-spinal  axis,  but 
is  quite  as  expressive  when  you  understand  it.  Both  terms, 
however,  mean  the  great  brain  and  spinal  center  of  the 
great  neural  organism  of  the  body,  an  organism  as  omni- 
present in  the  animal  mechanism  as  the  almost  everywhere 
to  be  found  blood  vessels.  The  neuraxis  is  the  axis  for 
the  entire  nervous  system.  Axis  is  the  Latin  for  axle  as 
you  know  and  means  a  thing  about  which  something  else 
revolves.  It  means  here  central  or  pivotal,  as  you  have,  all  of 
you,  learned  in  studying  physics  and  anatomy.  In  your  anat- 
omy of  the  skeleton  you  will  remember  the  second  cervical 
vertebra  above  which  and  around  whose  odontoid  process, 
the  atlas,  which  holds  up  the  cranium  as  the  fabled  Atlas 
did  the  world,  and  around  which  the  atlas  and  the  super- 
imposed cranium,  rotates.  The  term  neuraxis,  figuratively, 
but  quite  appropriately,  answers  for  cerebro-spinal  axis, 
because  the  rest  of  the  nervous  system  proceeds  from  and 
figuratively  revolves  around  it.  Neuraxon,  so  like  it  in  sound, 
means  the  axis  cylinder  process  of  neurone.  It  is  a  very 
essential  part  of  the  nerve  cell  or  of  the  neuron,  as  you  will 
see  as  we  proceed. 

You  see  this  little  Greek  word  vs.vpovt  with  its  con- 
tractions neu,  neur,  neuro,  etc.,  is  constantly  recurring  in  our 
precursory  incursions  into  the  interesting  domain  of 
neurology.     Term     after     term     will     come    into     use     like 


20 

neurectomy,  (vevpov,  a  nerve,  and  rgwav,  to  cut)  nerve 
cutting,  a  thing  the  surgeons  are  sometimes  too  prone  to 
do,  (as  neurologists  sometimes  think)  before  the  neurologist 
has    exhausted    his    resources    or     with)  it    consulting    the 

neurologist  as  we  sometimes  think  they  should,  and  a  thing 
they  often  do  to  our  great  relief  and  to  the  relief  of  the  patient 
as  well,  sometimes  before  neurotheraphy  has  been  thorough- 
ly tried  as  we  think  we  know  best  how  to  try  it,  as  in 
that  formidable  capital  operation  of  the  nervous  system 
Gasserian  Gangliectomy  or  Gasserian  neurectomy  or  neuro- 
tomy, the  cutting  out  of  the  ganglion  of  Gasser  from  the 
under  surface  of  the  brain,  an  operation  which  only  skilled  sur- 
geons should  undertake  after  wise  neurological  counsel.  You 
will  learn  more  about  this  subject  when  we  come  to  discuss 
trifacial  neuralgia  or  neuralgia  of  the  fifth  nerve  (from  ver^or, 
a  nerve,  and  aAyos,  pain)  sometimes  also  called  prosopalgia, 
from  prosopon,  the  face,  and  the  Latin  algia,  pain,  a  shoot- 
ing pain  involving  the  branches  of  the  fifth  nerve  or  three 
branch  nerves  of  the  face  and  its  ganglion  (Gasserian)  ;  a 
nerve  which  Sir  Charles  Bell,  a  great  Englishman,  once  at- 
tempting to  operate  upon  including  with  his  knife  the 
seventh  nerve,  and  thus  producing  surgically  a  form  of  that 
characteristic  facial  expression  palsy  which  now  so  univer- 
sally bears  his  honored  name,  now  so  interesting  to  neu- 
rologists. 

Neurilemma  (Ae^u?,  sheath  or  husk,  sheath  of  the 
nerve,  epinurium,  «",  upon,  and  vevpov,  nerve).  Neurility 
signifies  nerve  power  or  power  of  nerve  life,  impulse,  per- 
ception or  power  to  muriate,  if  by  warrant  of  philological 
analogy  we  may  be  permitted  to  use  such  an  expression. 
In  this  connection  there  is  one  term  which,  by  contrast  you 
will  remember,  after  1  mention  it,  as  having  no  just  warrant 
for    its    derivation,    a    gelatinous,    bad-smelling   product    of 


21 

animal  or  fish  putrefaction,  a  non- poisonous  ptomaine  when 
unmixed  with  other  ptomaines.  This  is  called  neuridin, 
which  I  consider  an  unfortunate  misnomer,  for  there  is 
little  or  no  nerve  in  it,  though  the  vagus  nerve  goes  to 
the  viscera  whose  decomposition  sometimes  causes  it,  and 
nerves  go  to  the  muscles  whose  decay  may  engender  it.  It 
and  its  poisonous  fellow  ptomaine  called  murine,  obtained 
partly  from  the  same  source,  which  acts  so  much  like  curare 
on  the  motor  nerve  terminals,  causing  dyspnoea,  convul- 
tions  and  death,  ought  to  be  substituted  by  more  suitable 
terms.  Neurine  should  pertain  to  the  nervous  system  only 
and  not  to  products  of  either  poisonous  or  non-poisonous 
decomposition  of  fish,  fowl,  flesh  or  viscera.  Sheppard  has 
used  and  applied  the  term  more  appropriately,  though  in  an 
unusual  way,  to  the  gray  matter  of  the  layers  of  the  cere- 
bral hemispheres,  which  he  called  the  neurine  batteries  of 
the  brain. 

There  is  also  the  term  psychosis,  from  ^xq,  the  soul,  the 
mind,  meaning  a  disease  of  the  mind  usually  functional,  and 
sycosis,  from  o-vkov,  a  fig,  used  to  designate  a  disease  of  the 
hair  follicles.  The  dermatologists  should  give  this  term  up  to 
us.  Everything  should  make  way  for  advancing  psychiatry 
and  its  designating  terms.  I  do  not  like  terms  that  confuse  the 
student  of  neurological  science  and  make  his  task  of  acquisi- 
tion more  difficult  than  it  is.  My  business  is  to  simplify 
your  work  and  clarify  your  course  through  your  curriculum. 
The  ponderous  volumes  written  up  to  date  and  by  meritorious 
authors  on  neurology  and  psychiatry  are  paralysing  enough 
to  contemplate,  but  if  you  will  listen  to  me  faithfully  and 
observe  the  illustrations  1  give  you  during  the  session,  I  will 
elucidate  the  subjects  upon  which  they  treat  to  the  best  of 
my  ability,  so  that  you  may  comprehend  them  when  you 
consult  the  great  text- books  of  the  great  masters  and    enjoy 


22 

the  leisure  of  the  early  days  of  your  practice  and  the  coming 
decades  of  your  professional  career  in  mastering  them.  You 
are  expected  to  master  the  salient  points  only  and  not  the 
entire   science  of    neurology  during   your  undergraduate  life. 

We  expect  to  make  you  successful  students  during  your 
course  in  neurology  and  not  expert  masters  of  the  subject; 
to  blaze  a  clear  pathway  and  clear  out  the  underbrush  of 
the  thickly  wooded  and  tangled  forest,  so  that  the  light  will 
shine  through  it,  and  to  direct  you  aright  so  that  you  may 
traverse  alone  and  better,  when  without  us  and  at  your 
leisure,  in  delighted  companionship  with  greater  leaders  of 
our  great  science  and  art.  There  are  great  names  in  neu- 
rology, greater  than  the  name  of  Agamemnon;  great  names 
since,  as  well  as  before  that  great  Agamemnon  in  neurophys- 
iology, Claude- Bernard.  Immortal  names  whose  memories 
you  will  revere,  and  yet  living  names  whom  you  will  honor. 
Charcot,  Claude-Bernard,  Marshall-Hall,  Beard,  among  the 
immortals  abroad,  Brown-Sequard,  Seguin,  Hammond,  Ami- 
don,  Amariah-Brigham,  Benjaman  Rush  among  our  own 
honored  dead  and  hosts  1  cannot  now  recall,  and  Virchow, 
the  venerable  chief  among  the  yet  living.  May  he  live  for- 
ever. You  may  be  surprised  that  1  mention  our  Benjamin 
Rush  as  chief  among  my  gallery  of  immortals,  for  he  was 
only  an  American,  and  great  names  in  American  medicine 
are  not  yet  in  good  form.  He  lived  and  died  on  the  wrong 
side  of  the  Atlantic,  like  McDowell  and  Morton,  and  yet 
awaits  a  place  in  Fame's  Pantheon.  But  scan  his  works 
and  words  well  and  you  will  see  that  even  he,  an  old-time 
American  doctor,  deserves  a  place,  if  not  in  the  temple  of 
modern  psychiatry,  yet  upon  Fame's  eternal  camping  ground. 

Some  day  in  your  time  the  world  will  applaud  more 
than  now  the  merits  of  Benjamin  Rush.  He  was  a  neuro- 
logical  giant  in  his  day.  He  saw  things  in  psychiatry  with 
astonishing  precision. 


Bourgery's  outline  lateral  view  anatomical  diagram  of  the  cerebro- 
spinaUaxis  or  neuraxis,  from  Quain's  anatomy,  showing  the  cerebro-spinal 
cavity  from  the  top  of  the  brain  within  the  cranium  to  the  end  of  the  spinal 
cord,  cauda  equina  and  coccyx.  F,  T  and  O  are  the  frontal,  temporal  and  oc- 
cipital lobes  of  the  cerebrum;  C,  P  and  Mo  are  the  cerebellum,  pons  Varolii 
and  medulla  oblongata;  M  and  Ms  show  the  upper  and  lower  extremities  of 
the  spinal  cord;  Ce,  the  cauda  equina  at  the  lower  end  of  the  spine  be- 
ginning with  the  last  lumbar  spinous  process;  V,  ganglion  of  the  fifth  nerve 
or  the  trigeminal,  or  ganglion  of  Gasser  with  its  three  branches  faintly 
shown;  C  L  shows  the  first  of  the  spinal  nerves  or  first  cervical  coming 
out  under  the  occiput,  and  CviII  is  the  last  or  lowest  cervical;  DI  is  the 
first  dorsal  or  thoracic  and  DXII  is  the  twelfth  or  lowest  and  last  dorsal.  The 
first  sacral  nerve  begins  at  Si ;  SV  is  the  fifth  sacral ;  S  is  the  sacral  plexus 
and  Col  is  the  coccygeal  nerve. 


CHAPTER  II. 

THE   NEURONE  AND  THE  NERVE  CELLS:    THEIR  COMPOSITION 
AND  CHARACTERISTICS. 


Notwithstanding  the  delicate  structure  of  the  higher 
functioning  neurones,  their  morphological  or  shape  differences, 
corresponding  to  their  grander  activities  in  the  scale  of 
being,  eminent  physiologists  tell  us  that  these  high  power 
neurones,  like  other  cells  of  the  body  of  lower  anatomical 
station  and  physiological  dignity,  possess  protoplasm  and  nu- 
clei, the  morphological  characteristics  of  which,  so  far  as  can 
at  present  be  unraveled  by  the  highest  powers  of  the  micro- 
scope, would  scarcely  seem  to  differ  from  those  of  the  cells 
of  less  noble  tissues,  to  account  for  their  greater  dignity. 
There  are,  nevertheless,  and  there  must  be,  certain  deli- 
cate differences  in  the  neurone  structure,  since  structure 
and  function  throughout  all  nature,  are  correlative,  like  the 
varied  mechanical  adjustment  of  varying  movement,  which, 
though  no  eye  has  yet  seen  and  no  glass  can  now  reach  them, 
must  yet  some  day  by  more  delicate  means  of  research  than 
are  now  at  hand  be  brought  to  light,  by  sight  of  science,  just 
as  we  know  in  daytime  there  are  stars  above  us,  though  we 
see  them  not  save  by  the  revelation  of  astronomy.  In  fact, 
notwithstanding  the  remarkable  uniformity  in  type  of  the 
nerve  cells  in  the  most  diverse  parts  of  the  central  nervous 
system,  Barker  assures  us  that  the  neurones  are  not  every- 
where so  similar  as  to  be  practically  indistinguishable  from 
one    another  and  cites  a  wealth  of  morphological    peculiari- 

[23] 


24 

ties  revealed  specially  by  the  research  methods  of  Golgi  and 
Ehrlich,  which  neurophysiologists  were    formerly    unable   to 

obtain.  Barker  gives  differences  of  internal  structure  of 
different  cell  groups  recorded  by  the  method  of  Nissl,  which 
he  regards  as  of  equal  importance  for  purposes  of  classifica- 
tion to  the  external  form  from  relations  discovered  by 
Golgi's  stain,  and  "Barker  knows  his  business"  as  well  as 
Golgi  and  Nissl,  Held,  Apathy  and  Foster,  or  any  other  in 
the  profession's  galaxy  of  cytologic  stars.  "There  are 
many  neurones  which  from  the  appearance  of  a  single 
example  stained  black  with  silver,  permit  an  absolute  decision 
as  to  their  source"  and  Barker  here  mentions  the  cells  of  the 
sensory  ganglia,  those  of  Purkinje  in  the  cerebellum,  the 
pyramidal  cells  of  the  cortex  and  certain  cells  of  the  hip- 
pocampus. Some  of  you  may  be  able  to  verify  in  the 
biological  laboratory  before  your  studies  here  are  ended, 
the  truth  of  this  verifiable  statement.  You  must  not  stop 
where  I  leave  you,  but  press  on  beyond  to  the  entrancing 
neuroanatomical  and  neurophysiological  landscape,  now 
pointed  out  and  with  wider  and  ever  widening  microscopical 
vision,  as  you  grow  in  knowledge  of  the  wondrous  and 
complicate  mechanism  of  man's  marvelous  nervous  system, 
till  you  pass  beyond  the  horizon  which  now  apparently,  but 
not  in  reality,  bounds  your  progress.  There  is  light  for  you 
in  the  far  beyond,  and  in  the  sweet  by  and  by,  but  we  have 
not  time  to  go  there  now  and  many  suns  must  rise  and  set 
before  you  may  reach  the  glorious  goal. 

After  the  bird's-eye  view  I  have  given  you  of  the 
beautiful  beyond  opportunities  of  investigation,  it  will  in- 
terest you  just  now  to  know  that  you  are  not  expected  to 
know  all,  as  only  the  great  masters  see  the  entrancing  field 
of  cytology,  (for  that  is  what  it  is  called,  kvtos,  a  cell,  Xoyos, 
a  discourse),  in  order  to  get  your  degree  from  his  college,  but 


25 

you  will  be  expected  to  know  something  of  what  the  master 
minds  are  doing,  and  a  good  deal  of  what  we  show  you, 
that  you  may  wisely  follow  them  after  you  shall  have 
learned  to  walk  and  not  creep  in  their  cytologic  footsteps. 
The  cytologic  way  in  physiology  will  interest  you  quite  as 
much  as  the  Milky  Way  may  have  entranced  you  in  your 
preparatory  college  survey  of  astronomy,  for  it  is  strewn 
with  marvels  of  light  on  the  wondrous  life  and  potencies  of 
living  animal  matter.  Cytology  is  a  study  of  the  neurones, 
or  cells,  and  astronomy  is  a  study  of  the  stars  and,  used 
like  astronomy  in  its  broader  sense,  the  study  of  the 
neurones  is  a  study  of  all  that  pertains  to  the  cells,  or 
neuronomy,  if  the  philologists  and  the  linguists  will  permit 
the  term,  in  the  sense  that  it  means  a  grazing  among  the 
nerve  cells  and  their  belongings.  The  neurone  then  is  the 
complete  nerve  cell  or  ganglion  cell,  embracing  the  nucleus, 
nucleolus,  axis  cylinder  process,  or  axone  and  dendrites 
(all  processes,  collaterals  and  terminations)  grouped  into 
a  nerve  individuality  or  independent  unit.  The  neurone 
does  not,  through  prolongations,  intertwine  with  processes 
from  neighboring  cells;  it  does  not  anastomose  like 
terminals  of  the  vascular  system  as  in  the  capillaries.  It 
is  a  separate  and  distinct  personality,  so  to  speak,  capable  of 
coming  into  contact, but  not  of  mixing  or  interlacing  or  merging 
with  other  neurones  so  as  to  lose  its  individual  identity.  It  is 
not  a  mixer,  but  stands  upon  its  own  individuality  and  here 
are  some  examples  for  your  inspection  of  the  nerve  units 
which  we  now  call  neurones.  With  this  wider  and  more 
definite  understanding  they  might  as  well  have  been  called 
cells  as  heretofore;  for  they  are  the  same  cells  known 
before,  only  we  have  become  a  little  better  acquainted  with 
them  and  know  their  nature,  relations,  and  distinctive  in- 
dividuality more  familiarly,  and  talk  of  them  in  a  broader  and 


26 

more  inclusive  sense.  When  we  say  neurone,  we  mean  all 
that  pertains  to  the  cell;  its  nucleus,  nucleolus,  its  axis 
cylinder  process  or  neuraxon,  the  dendrites,  the  myelin 
sheath  of  its  collaterals  and  its  split  up  end  brushes 
or  terminal  arborizations.  The  neuraxons  and  dendrites 
of  different  cells  come  together,  but  do  not  anatomically 
anastomose.  The  neurones  mingle  but  do  not  mix, 
they  associate  but  do  not  join  together,  they  are  well 
acquainted  with  each  other,  especially  the  psychic  neurones 
of  the  several  layers  of  the  gray  cortex  of  the  brain,  and 
they  are  of  the  same  blood  as  their  neighbors,  but  they  are 
neighbors  only,  units  of  adjoining  families,  not  married  to 
each  other.  They  are  separate  and  distinct  but  yet  intimate 
friends,  working  side  by  side,  often  in  the  same  nerve  center 
to  the  same  neurophysical  or  neuropsychical  purpose. 

The  neurones,  like  cells  everywhere,  reveal  under  the 
microscope  evidences  of  change  in  composition  from  excessive 
and  toxic  impression.  Dexterity  and  disintegration  in 
exercise,  waste  and  work,  rest  and  repair,  are  correlative 
terms  in  the  nervous  system,  as  in  the  muscular.  The 
microscope  shows  this  among  the  muscle  cells,  as  it 
does  the  ravages  of  disease,  among  the  neurones. 
Micro-physiologists  have,  by  diligent  labor,  made  brilliant 
discoveries  concerning  the  peripheral  and  central  nerve 
cells.  The  neurones  of  the  cerebro-spinal  nerve  centers 
and  the  peripheral  nerves  have  been  examined  before 
and  after  exercise,  before  and  after  alcohol  and  mer- 
cury, nicotine,  lead,  phosphorous,  arsenic,  strychnia  and 
various  other  poisons  and  after  the  withdrawal  of  the  blood 
supply  from  the  neurones,  as  in  anemic  '  neurasthenia  and 
before,  which  experiments  have  thrown  much  light  on  the 
beginnings  of  disease,  not  only  in  the  neurones,  (or  entire 
nerve   cells)   but   of  disease  found  in  the    neurones  in    con- 


27 

nection  with  persons  who  have  died  of  other  than  recognized 
nervous  diseases. 

Neurones  directly  or  indirectly  suffer  in  many  diseases, 
probably  in  all,  as  we  might  learn  through  more  ex- 
tended research.  So  that  all  diseases  may  interest  you 
in  the  study  of  the  normal  and  abnormal  nerve  cell  or 
neurones.  All  acute  and  chronic  degenerative  processes  in 
the  nervous  system  appear  to  begin  or  end  in  the  involve- 
ment of  nerve  cells.  You  will  learn  in  the  biological 
laboratory  something  of  toxic  cells,  their  chromatolysis, 
cell  swellings  and  cell  shrinkages,  of-  remote  and  central 
degenerate  reaction  from  cell  or  peripheral  nerve  injury,  the 
effects  of  infections  and  intoxications,  chronic  and  acute, 
from  disease,  autotoxins  from  within,  or  poisons  from  with- 
out, or  from  intense  heat  and  the  restitution  which  follows 
the  restoration  to  normal  temperature.  We  cannot  here 
discuss  these  matters  in  extenso,  but  a  hint  to  the  wise  is 
sufficient.  You  will  not  need  to  seek  diversion  in  novel - 
reading  or  the  theatre.  You  will  find  it  in  the  study  of 
the  neurones,  beyond  what  we  can  teach  you  in  this 
amphitheatre  and  there  discover  how  much  stranger  is 
scientific  neurological  truth  than  any  fiction. 

The  composition  of  the  cell  body  or  bulb  of  the  neurone  is 
much  like  the  white  of  an  egg  and  is  called  protoplasm,  and 
in  cytologic  technicality  cytoplasm.  All  nerve  cells  or  neurones 
have  a  nucleus  and  the  nucleus  a  nucleolus  or  ultimate 
or  lower  nucleus. 

The  neurone  is  not  throughout  a  homogeneous  sub- 
stance, as  you  are  ready  to  infer  from  its  divisions  for 
functionating  purposes,  since  modifications  of  structure,  in 
the  nerve  cells  as  elsewhere,  as  we  can  discern  by  analogical 
reasoning  if  not  by  search  of  scientific  resource,  vary  with 
differences  of  function.     A  viscid-like  plasma  is  thrown  around 


28 

and  between  the  net- like  work  of  granular  fibers,  which 
make  up  the  body  of  the  neurone  (neuroglia).  The  neu- 
rone has  within  it  chromophile  granules,  so- named  because 
they  may  be  stained  by  aniline,  silver  and  other  color  agents. 

Each  one  of  the  many  meritorious  text-books  on  neurology 
sanctioned  by  this  chair  in  the  annual  announcement  has 
some  or  several  distinctive  features  of  interest  in  text  or 
illustration,  Dana,  Mills,  Gowers,  Ross,  Dercum,  Church,  and 
Peterson,  Potts,  Gray,  Hamilton,  Hammond,  Hirt,  Ranney, 
Starr,  besides  the  European  authors  which  some  of  you 
have  in  your  mother  or  acquired  European  language.  Each 
and  all  of  them  will  enlighten  you  further  than  1  can  today 
by  text  or  illustration,  or  both.  Many  of  them  have  illustra- 
tions that  will  aid  you  further  than  I  can,  by  taking  your 
time  during  the  hour  to  show  you  under  the  lens  or  on 
the  board.  Refer  to  your  text-books  for  the  picture  paint- 
ing if  for  nothing  else,  of  any  part  of  my  subject  which  I 
may    not    make  plain  to  you  during  the  lecture  hour. 

You  often  hear  it  said  that  "life  exists  in  its  simplest 
form  in  the  cell,"  that  organs  are  but  aggregations  of  cells, 
and  animal  organism  but  an  aggregation  of  organs  intimately 
associated  and  related,  and  that  life  like  "light  and  sound 
are  modes  of  motion,"  yet  the  neurone  is  more  wondrously 
complicated  physiologically  than  it  looks  and  as  we  are  yet 
to  learn,  probably  through  higher  and  greater  powers  of 
micro-chemical  research.  Just  what  chemistry  is  constantly 
teaching  us  in  regard  to  its  so-called  chemical  elements 
and  some  of  its  so-called  simple  compounds  like  N  O2, 
the  air  we  breathe,  for  instance. 

During  your  leisure  hours  of  relaxation  from  the  severe 
studies  of  your  college  curriculum  and  in  your  vacation  you 
may  find  profit  in  scanning,  if  you  have  not  the  time  to 
read  closely,  some  of    the  leading    medical  journals    of   the 


29 

day.  In  them  you  will  find  articles,  editorials  and  para- 
graphs that  will  impress  your  work  on  your  minds  and  help 
to  give  you  valuable  stimulus  and  incentive  to  study. 
Apropos  of  our  subject  is  the  following,  reflecting  current 
professional  opinion  respecting  the  value  of  the  study  of 
the  neurones  or  entire  nerve  cells":* 

"The  beginnings  of  disease  must  necessarily  consist  in 
undiscernable  alterations  in  cellular  structure  and  function, 
and  it  is  probable  that  changes  of  this  character  underlie 
the  so-called  functional  disorders;  namely,  those- unattended 
with  evidences  of  structural  or  organic  lesion.  Recent  ad- 
vances in  staining  methods  have,  in  fact,  helped  to  disclose 
minute  changes  in  cells  subjected  to  various  morbid  in- 
fluences, and  thus  lend  support  to  the  view  briefly  ex- 
pounded. Such  alterations  in  cellular  nutrition  may  result 
from  the  action  of  substances  normally  generated  within  the 
body,  but  now  produced  in  excess  or  in  deficiency,  in  con- 
sequence of  some  derangement  in  metabolic  equilibrium,  or 
in  themselves  abnormal,  or  introduced  from  without  in  con- 
nection with  infection  or  intoxication. 

Bearing  upon  this  subject,  Dr.  Theodore  Klingmannt  has 
recorded  the  results  of  some  observations  on  the  cells  of 
certain  algas  and  protozoa.  It  was  found  that  a  variety  of 
changes  could  be  induced  by  artificial  means:  (First,) 
Changes  identical  with  the  physiological  appearances 
occurring  in  the  cells  when  they  die  gradually  from  natural 
causes;  (second,)  changes  of  a  purely  chemical  character; 
(third,)  changes  of  a  pathological  nature  due  to  toxic  sub- 
stances— the  results  varying  with  the  intensity  of  the 
operating  influence.  In  one  series  of  observations  metallic 
substances  were  employed  to  induce  the  changes  described. 

*Conclusion  of  an  editorial  in  the  New  York  Medical  Record,  April  20,  1901. 
\American  Journal  oj  Insanity,  vol.  Ivii.,  No.  3,  p   519. 


30 

In  the  second  scries  blood  serum  obtained  from  patients 
suffering  from  various  forms  of  so-called  functional,  nervous, 
and  mental  disorders  was  substituted.  Analogous  results 
were  obtained  in  both  series  of  experiments.  A  great  variety 
of  pathological  conditions  was  found  in  the  ganglion  cell  of 
rabbits  and  guinea-pigs  treated  with  injections  of  toxic 
serum  in  varying  dilution,  the  form  of  chromatolysis  (cell 
coloring) varying  with  the  strength  of  the  serum  and  the  period 
of  its  activity.  The  use  of  blood  serum  from  healthy  in- 
dividuals, on  the  contrary,  yielded  negative  results." 

You  cannot  keep  yourself  in  normal  touch  with  the 
advance  in  your  profession  without  a  few  representative 
periodicals  for  daily  reference  and  there  is  a  profusion  of 
good  journals  in  this  country.  Take  a  few  choice  ones  and 
you  will  not  forget  what  you  have  been  or  shall  have  been 
taught  in  this  college  and  with  the  help  they  will  give  you, 
will  constantly  add  to  your  store  of  medical  knowledge. 

Morbid  changes  in  the  neurones  have  been  found  to 
end  in  fatty  degeneration.  Changes  in  the  neurones  of  the 
gray  matter  of  the  brain  have  been  found  in  insanity,  in 
acute  delirium,  delirium  tremens,  in  paralytic  dementia, 
hypothermia  or  extra  high-grade  fever,  in  the  bubonic 
plague,  in  typhoid  fever,  in  infectious  maladies  and  poison- 
ings and  as  I  have  already  stated,  in  bromide  of  potash 
poisoning,  besides  the  other  drugs  already  named.  In 
uremia,  in  multiple  sclerosis,  in  chorea,  in  tetanus,  ataxia, 
lateral  sclerosis,  poliomyelitis  anterior,  etc.,  and  in  the 
peripheral  nervous  system,  as  in  polyneuritis,  or  inflammation 
in  many  nerves,  neuralgia,  that  painful  paroxysmal  affec- 
tion of  the  peripheral  sensory  nerves,  as  of  the  face,  above 
the  orbits,  about  the  mouth  and  jaws,  in  the  tongue,  etc. 

Bevan  Lewis'  and  Ford  Robertson's  illustrations  of  dis- 
eased neurones  will  instruct   you    much.      One    thing  about 


31 

the  neurone's  pathology  I  wish  to  impress  here,  viz.:  When 
the  nucleus  of  a  neurone  is  diseased  it  seems  to  die,  while 
its  neuroglia,  neurites  or  dendrites  may  become  diseased 
and  yet  may  recover.  But  disease  damage  done  to  the 
proliferating  neurites  or  dendrites  or  neuroglia  also  affect  the 
function  of  the  neurone  body. 

The  loss  of  the  customary  peripheral,  afferent  or  sen- 
sory impression  has  been  shown  to  cause  changes  in  the 
central  spinal  cord  neurones  and  the  cord  cell  changes  also 
contribute  to  make  those  departures  from  the  normal  ana- 
tomical and  physiological  state  of  the  neurones  in  the  cerebro- 
spinal axis  or  central  nervous  system,  the  peripheral  or 
sensory  motor  nervous  projection  system  and  sympathetic 
nervous  system.  This  we  call  the  pathology  of  nervous 
disease. 

Pathology  in  the  nervous  system,  or  neuropathology  as 
elsewhere  in  the  animal  organism,  is  abnormally  changed 
anatomy,  and  disease,  as  we  see  it  ante-mortem,  is 
abnormally  changed  physiology.  It  is  physiology  perverted 
by  pathology.  After  the  death  of  a  part  it  is  pathological  or 
necroscopic  or  morbid  anatomy.  Disease  of  the  nervous 
system  is  pathology  of  the  nervous  system  in  action.  Its 
structural  causes  and  results  make  the  pathology,  its 
functional  results  make  symptomatology.  Morbid  anatomical 
findings  may  also  be  a  cause  of  other  disease,  than 
that  diseased  action  which  produces  them.  The  real  disease, 
with  its  strictest  definition  would  be  in  the  nervous  sys- 
tem or  elsewhere,  that  is,  the  altered  molecular  activity 
that  leads  to  the  changes  in  the  cells  producing  the  changes 
in  the  organic  structure,  causing  the  organic  functional 
changes  or  symptoms.  This  is  true  of  the  nervous  system 
as  of  every  other  part  of  the  body.  The  microbe  or  bacillus 
or  materies  morbi  or  psychic  impress,  changes  the  molecules 


S2 

that  change  the  cell,  that  change  the  motion,  that  change  the 
function  of  the  changed    frame  that  nature  built,  as   we  see 

it  in  disease.     That    change,   when    the    nervous    system  is 
specially  involved,  we  call  nervous  disease'. 

The  central  neurones  and  the  nervous  system  are  subject 
to  slow  chronic  inflammation  associated  with  syphilis,  tuber- 
culosis and  the  poisons  already  mentioned  and  by  auto-toxic 
or  toxic  products  generated  by  and  within  the  body.  Be- 
sides urea,  already  mentioned,  which  may  so  impress  the 
psychic  neurones  and  the  vaso- motor  centers  of  the  brain 
as  to  cause  the  unconsciousness  of  coma  and  may  im- 
press the  psycho -motor  centers  so  as  to  cause  spasms  and 
convulsions,  the  body -generated  poisons  of  gout  and  rheuma- 
tism, (uric  and  lithic  acid)  and  the  sugar  of  diabetes  may 
engender  changes  in  the  neurones  or  proceed  from  changes 
in  the  neurones  of  the  nerve  centers  as  they  do  in 
other  tissues  of  the  body.  Thus  you  have  diabetic 
coma  as  well  as  dropsy  which  may  be  caused  by  irrita- 
tion in  the  floor  of  the  fourth  ventricle  whence  the  great 
vagus  nerve  arises,  along  with  other  cerebral  nerves,  as 
well  as  by  changes  supposed  to  primarily  take  place  in  the 
liver  or  elsewhere.  The  physiologists  have  generated  gly- 
cosuria by  mechanically  irritating  the  floor  of  the  fourth 
ventricle  of  the  brain.  They  have  also  induced  it  by  fret- 
ting dogs,  by  keeping  them  confined  in  sight  of  other  dogs 
at  play.  As  uric  acid  irritates  the  muscle  and  joint  tissue 
into  inflammatory  action,  as  you  see  so  fatally  illustrated  in 
the  acute  myocardites  and  pericardiac  inflammatory  effusions, 
that  impede  and  arrest  this  vital  organ's  action,  so  it  may 
locate  in  and  similarly  damage  the  delicate  structures  of  the 
brain,  as  it  so  often  does  the  muscles  and  joints,  changing  the 
anatomical  and  physiological  conditions  of  the  neurones  and 
connective  tissue  or  neuroglia  into  pathological  states  and  sim- 


33 

ilarly  involving  the  peripheral  nervous  system,  as  in  the  rheu- 
matic and  other  auto-toxic  neuritides  or  inflammatory  states 
of  the  nerves  from  self-generated  or  body-generated  poisons 
or  from  poisons  from  without  the  system  as  alcohol,  arsenic, 
lead,  etc.  This  autoxicity  might  be  called  the  sub-conscious 
suicidal  tendency  of  the  body.  It  is  in  some  cases  termed 
a  diathesis,  which  is  a  congenital  or  inborn  or  very  early 
acquired  aptitude  of  the  system  to  actively  take  on,  under 
slight  external  influence,  certain  morbid  states.  Diathesis  is 
from  TiOevai,  to  place,  and  &a,  through,  and  thus  we  have  the 
influence  of  the  gouty  or  arthritic,  rheumatic,  strumous,  or 
tubercular,  catarrhal,  haemorrhagic,  aneurismal,  psychopathic, 
neuropathic  diatheses,  etc.  Toxines  and  habitual  or  occasional 
autotoxicities,  influence  and  precipitate  the  development 
of  mental  and  nervous  diseases  through  predisposition  of 
the  neurones  and  their  connections  of  the  cerebro-spinal 
axis  and  the  peripheral  nervous  system,  which  includes  the 
the  sympathetic  and  its  vasomotor  system,  especially  the 
latter,  as  when  the  haemorrhagic  diathesis  appears  in  disease. 

Thus  you  see  in  studying  the  nervous  system  in  all  its 
cell  diseases  and  relations,  you  must  understand  the  whole 
man,  for  it  is  influenced  by  so  much  that  affects  the  body 
in  general  and  its  diseases,  as  it  also  so  much  influences  the 
organism  as  a  whole  and  in  its  parts.  In  this  vast  chain 
of  being,  the  neurones  make  many  links  and  all  the  organs 
and  viscera  are  links  of  strength  or  weakness.  Ancestral 
organic  endowments  are  links  of  direct  or  atavic  descent, 
that  go  to  make  the  chain  of  health  or  disease  in  the 
nervous  system  stronger  or  weaker,  and  knowledge,  or 
lack  of  knowledge  of  these  matters,  will  make  you  stronger 
or  weaker  as  practitioners  of  medicine. 

The  neurones  are  nourished  by  the  blood,  as    all  other 

*Vide  author's  paper  on  haemophilia,  Alienist  and  Neurologist,  July,  1887,  and  pro- 
ceedings St.  Louis  Medical  Society,  1884, 


34 

parts  of  the  body  are,  but  not  in  the  same  simple  way  as  the 
other  and  courser  tissues.  A  more  intimate  relationship 
appears  to  exist.  Adamkiewicz*  in  describing  the  fine 
anatomy  of  the  blood  vessels  of  the  large  intervertebral 
ganglion  of  the  brachial  plexus  says: 

"The  ordinary  arterial  capillaries  give  off  finer  capillaries, 
(vasa  serosa)  which  are  so  fine  as  to  transmit  only  the  fluid 
constituents  of  the  blood  and  none  of  the  corpuscles" — finer 
than  those  which  carry  only  the  white  blood  corpuscle  vessels 
as  those  to  the  sclerotics  of  the  eyeball,  for  instance. 
These  vessels  go  to  the  neurone,  spread  out  and  envelop 
it  like  a  glove  and  then  narrow  down  to  their  original  size 
and  empty  into  another  arteriole  capillary.  This  demon- 
stration in  the  intervertebral  ganglion  has  not  been  so  well 
proven  as  yet.  But  Adamkiewicz  reasons  that  the  neurones 
of  the  cortex  of  the  brain  are  similarly  nourished  in  this 
wise.  He  points  out  that  the  exposed  cortex  is  perfectly 
tolerant  of  a  forcible  stream  of  distilled  water,  which  if  in- 
jected into  the  carotid  will  immediately  produce  nystagmus, 
extensor  spasm  all  over  the  body,  and  disturbance  of  the 
pulse  and  respiration.  His  anatomical  argument  is  that 
the  vascular  network  in  the  cortex,  as  demonstrated  by  the 
injection  of  carmine  gelatine,  is  much  closer  in  those  parts 
of  the  cortex  which  are  richer  in  ganglia  than  elsewhere, 
and  concludes,  "all  arteries  which  enter  the  brain  and  spinal 
cord  of  man  and  of  animals,  at  least  of  the  higher  animals, 
end  on  the  further  side  of  the  capillaries  in  very  fine  plasma 
vessels  which  contain  ganglion  cells,  in  diverticular  ex- 
pansions." For  ready  remembrance  the  neurones  may  be 
likened  to  little  islands  surrounded  by  water.    Nature  seems  to 

*Stehen  Alle  Ganglienzellen  mil  den  Blutgefassen  in  Directer  VerbindunK  Nurologische 
Cenlralblatt  fur  January,  1900. 

W.  H.  B.  Stoddard  in  the  Join/nil  oj  Mental  Science   for  January.   1901,   Roes   over 
this  subject  in  English. 


35 

love  to  invest  them,  as  it  does  other  parts  of  the  nervous 
system,  with  serum.  The  spinal  cord  hangs  in  the  vertebral 
canal,  closely  filling  it,  like  a  substance  suspended  in  a  bottle 
of  water.  The  arteries  of  the  brain  have  their  perivascular, 
serum  filled  spaces,  and  the  lymph  of  these  perivascular 
spaces  is  the  same  as  that  of  the  ventricles  and  the  spinal 
cord.  The  brain  has  its  serous  arachnoid  investment  and 
its  serum  filled  ventricles,  and  the  nerves  and  the  neurones 
float  in  microscopic  rivers  of  water,  so  to  speak,  the  serum 
surrounding  the  nerves  and  cells.  The  subarachnoid  spaces 
communicate  with  the  fourth  ventricle  and  they  with  each 
other  except  the  fifth,  and  with  the  cord  they  contain  the 
spinal  fluid. 

The  brain,  spinal  cord,  sympathetic  and  sensory  and 
motor  parts  of  the  peripheral  nervous  system  have  systems 
of  irrigation  as  well  as  a  sewage  system,  systems  of  recon- 
struction or  nutrient  supply  and  systems  for  waste  removal, 
as  other  parts  of  the  organism  do  (arterial,  venous, 
lymphatic  systems).  An  idea  of  the  irrigation  or  nutritional 
system  of  the  brain,  for  instance,  may  be  obtained  from  a 
study  of  the  circle  of  Willis  and  its  distribution  and  from 
an  examination  of  the  fluid  filled  spaces  around  the  blood 
vessels  and  perivascular  spaces  and  the  fluid  filled  spaces 
of  the  five  ventricles  of  the  brain  and  of  the  subarachnoid 
spaces.  The  illustration  I  show  you  here  is  one  of  the 
cerebral  perivascular  spaces.  The  walls  of  the  arteries 
and  veins  of  the  brain  cortex  are  directly  enveloped  by 
outer  walls  of  pia  mater  which  secrete  lymph  and  make  up 
the  perivascular  vessels  and  lymph  spaces.  This  lymph 
contributes  to  the  nourishment  of  the  surrounding  neurones 
and  neuroglia. 


1111  STRATING   A   PART   OF  Till:   BRAIN'S   IRRIGATION   SYSTEM. 


FIG.   2. 


The  D,  A,  P,  giving  the  memorial  word  dap,  show  the  relative  position 
from  above  downward  or  from  without  inward  of  the  cerebral  minenges,  dura, 
arachnoid  and  pia,  indicated  also  by  numbers  1,  2  and  3.  Fig.  1  shows 
the  subdural  space,  2  the  arachnoid  and  3  the  pia,  between  the  layers  of 
of  which  are  seen  ramifying  small  vessels  of  the  brain  which  branch  down- 
ward to  penetrate  the  substance  of  the  cortex,  5,  7,  8  and  9,  invested 
by  delicate  pial  sheaths,  with  lymph  between  their  walls  and  those  of  the 
vessels  of  the  perivascular  spaces    6. 


ISOLATED   ARTERIOLES  AND   PERIVASCULAR   LYMI'M   Sl'ACES 
OF  THE   BRAIN. 


FIG.   3. 


FIG.   4. 


— An  artery  from  the 
cortex  cerebri  in  longitudinal 
section.  Mar/n.  SO.  Numbers 
of  fine  fibres  are  seen  streaming 
into  the  brain-substance. 


—Section  from  the  cornu  Ammonis, 
snowing  perivascular  and  pericellular 
lymph-spaces.  Stained  with  carmine. 
Magn.  150. — a,  Capillary  vessel  in  a 
perivascular  lymph-space ;  b,  pericellular 
lymph-space  directly  continuous-  with 
the  former.  Two  leucocytes  are  seen 
in  the  pericellular  space  c,  and  one  in 
the  space  b.   (Q\mx  s\fc  VtVfcYJ) 


FIG.   5. 


Fig.  3,  isolated  arteriole;  Fig.  4,  arteriole  surrounded  by  perivascular 
spaces;  Fig.  5,  a  distended  perivascular  space  with  arteriole  atrophy,  after 
Milner  Fothergill. 


NEURONES  OF  THE  BRAIN    AND  SPINAL  CORD.      "PSYCHIC  CELLS"  OR  NEURONES 
OF   DIFFERENT    VERTEBRATES.     NEURONES   BELOW 
INVOLVED  IN   DISEASE. 
FIG,   7.  FIG.  8. 


FIG.  11.  FIG.  6.  FIG.  10. 


FIG.  9. 


Fig.  8.  A  pyramidal  cell  or  central  neurone  from  the  cortex  of  the  cere- 
brum with  the  dendritic  ramifications  (dendrites,  protoplasmic  process). 
Each  process  gives  off  a  great  number  of  bud-like  branches.  The  nerve 
fiber  of  the  cell,  or  axis  cylinder  process  is  designated  ax.  The  terminal 
fibrils  of  the  axis-cylinder  process  go  on  some  distance  from  the  cerebral 
cortex  to  other  portions  of  the  brain  or  cord,  where  they  surround  the  den- 
drites of  a  ganglion  cell.  This  neurone  begins  and  ends  within  the  central 
organ,  and  is  termed  a  central  neurone. 

Just  below  Fig.  8  is  (Fig.  9)  a  ganglion  cell  with  its  dendrites  from  the 
anterior  horn  of  the  spinal  cord;  among  its  ramifications  are  seen  the  ter- 
minal fibrils  of  the  nerve  fiber  belonging  to  the  central  neurone.  The  axis 
cylinder  process  (ax)  emerges  from  the  central  organ  and  passes  to  the  soft 
parts  in  the  periphery.  The  entire  neurone  is,  therefore,  called  a  peripheral 
neurone. 

The  third  illustration  below  (Fig.  10,  from  Ford  Robertson,  Plate  xxix) 
shows  in  marked  contrast,  a  pyramidal  nerve  cell  (neurone)  of  the 
cerebral  cortex  from  a  case  of  chronic  tuberculosis  of  the  kidneys  and  blad- 
der, showng  varicose  atrophy  of  protoplasmic  processes  (dendrites) .  Here  is 
an  intra-neural  change  dependent  upon  the  extra-neural  disease  tuberculosis. 
These  changes  in  the  psychic  neurones  account  for  some  of  the  peculiar 
psychic  symptoms  of  tuberculosis. 

Immediately  to  the  left  of  Fig.  8  is  an  illustration  (Fig.  7)  from  Ramon 
y  Cajal  of  the  "psychic  cell"  or  neurone  in  different  vertebrates  used  for 
comparison.  They  show  also  the  remarkable  morphological  resemblances, 
considering  the  apparent  and  generally  believed  difference  in  psychic 
manifestation  of  these  neurones  of  mental  function  in  animals  and  man. 

The  upper  series  of  cells  shows  the  "psychic"  cell  in  different  verte- 
brates: A  is  the  psychic  neurone  of  the  frog;  B,  of  the  newt;  C  of  the 
mouse;  D,  of  man.  The  lower  series  show  the  stages  of  growth  of  a  single 
neurone;  a,  neuroblast  with  axis  cylinder  process  just  commencing;  b, 
panicle  commencing;  c,  panicle  and  axis  cylinder  process  more  advanced; 
d,  collaterals  of  neurone  or  axis  cylinder  appearing;  e,  collaterals  of  cell 
body  appearing  (Ramon  y  Cajal). 

Underneath  this  illustration  from  Cajal  is  an  illustration  (Fig.  11)  from 
Ford  Robertson,  designed  to  show  the  neuraxone  or  axis-cylinder  process  of 
a  cortical  neurone  from  a  case  of  exophthalmic  goiter,  a  nervous  disease 
in  which  the  sympathetic  nervous  system  is  believed  by  most  authors,  to  be 
chiefly  involved,  a  vaso-motor  and  trophoneurosis. 

Compare  its  appearance  with  the  proliferations  of  the  pyramidal  cortical 
neurone  (Fig.  10)  affected  with  tuberculosis  beside  it  already  referred  to, 
showing  the  varicose  atrophy  of  protoplasmic  processes,  connected  with 
tuberculosis  of  kidney,  etc. 

Fig.  6  shows  a  normal  neurone. 

Illustrations  of  other  neurones  will  be  shown  later. 


CHAPTER  III. 

THE   NEURONE  AND  THE    NERVE    CENTERS,   CONTINUED;     THE 

NEURONE  THEORY,   ASSOCIATION   NEURONES, 

PROJECTION   FIBERS,   ETC. 


Remember  the  illustration  of  the  standing  bricks  in  a  row 
starting  to  fall  atone  end.  When  first  the  end  one  falls  toward 
the  others  each  falls  successively  in  its  turn  after  the  preceding 
one  and  communicates  the  impression  it  has  received  to  its 
adjoining  fellow,  it  in  turn  communicates  or  passes  on  the 
impression  it  has  received  to  the  next  as  in  the  blocks 
before  us.  This  is  the  way  the  neurones  act  toward  each 
other.     This    is   the    philosophy  of   the  neurone  theory. 

The  neurones  are  anatomical  units  with  an  independ- 
ent, yet  communicable  function,  like  the  students  in  this 
great  audience.  They  are  physiologically  individual  and 
independent,  yet  they  are  members  of  a  neural  community 
like  the  free  independent  American  citizen  who  is  never- 
theless so  dependent  upon  his  fellows  in  the  community  for 
his  welfare  that  he  does  not  seek  to  make  a  hermit  of  him- 
self and  live    alone. 

The  neurones  influence  each  other  by  contact  but  not 
by  being  blended  with  them,  by  contiguity  and  not  by  con- 
tinuity, as  Doctor  Charles  Potts  has  so  aptly  expressed  it 
in  the  excellent  little  student's  manual  some  of  you  carry 
to  the  class  room  with  you  with  my  approbation.  The  neu- 
rones wait  on  each  other,  attend  to  each  other's  impressions 
and    wants  in  a  manner.     They  are  pretty    closely   related, 

[36] 


37 

engaged,  but  not  married  in  indissoluble  union  of  function. 
Yet  they  are  very  nearly  so,  for  the  destruction  of  one  or 
more  of  one  group  or  nerve  center  in  the  economy  may 
materially  influence  the  welfare  of  the  other  contiguous 
neurones. 

A  community  of  interest  pervades  certain  groups  of  neu- 
rones in  the  brain  or  spinal  cord,  which  make  up  nerve 
centers.  According  to  location  and  description,  these  centers 
are  called  cerebral  nerve  centers,  spinal  nerve  centers, 
cerebro- spinal  nerve  centers,  ganglion  nerve  centers,  psychic 
or  mind  impression  and  expression  nerve  centers,  motor  or 
psycho -motor  nerve  centers  or  the  centers  of  cerebral  locali- 
sation where  motor  impulses  arise  in  the  brain  or  cord  and 
go  from  them.  They  are  sometimes  called  also  kinesodic 
centers.  There  are  also  sensory  centers  of  the  brain  or  cord 
where  sensory  impressions  are  received  and  sent  on  to  higher 
centers  or  across  the  spinal  cord  to  be  there  acted  upon, 
and  transformed  into  motion  in  the  anterior  horns  of  the  spinal 
cord.  The  latter  are  called  aesthesodic  centers  and  the 
nervous  mechanism  that  receives  these  impressions  has 
been  called  the  aesthesodic  system.  This  system  'is  made 
up  of  the  different  sensory  nerves  and  their  receptive 
centers  as  in  the  posterior  columns  and  root  zones  of  the  • 
spinal  cord,  as  the  kinesodic  or  motor  nervous  system 
is  made  up  of  the  different  motor  nerve  centers  and 
nerves  leading  from  the  centers  of  the  anterior  columns 
of  the  cord,  the  anterior  horns  or  cornuas  and  the  psycho- 
motor areas,  grouped  chiefly  about  the  Rolandic  area 
of  the  brain. 

PROJECTION    FIBERS,   ASSOCIATION    CENTERS,   TRACTS 
AND  COMMISSURES. 

In  your  study  of  the   coarse    anatomy   of   the    brain    in 
the    dissecting    room    you    learned    about   the   brain's    great 


38 

commissure,  the  corpus  callosum  and  the  lesser  commissures 
of  the  third  ventricle  and  about  the  conducting  strands 
of  the  great  corona  radiata,  etc.,  and  from  there  downward. 
These,  you  discovered,  connected  one  portion  of  the 
cerebral  structure  with  another.  The  great  corpus  cal- 
losum connected  the  two  lateral  hemispheres,  its  surface 
forming  important  landmarks  and  points  of  departure  in  our 
own  dissections,  the  anterior  cerebrals  reflecting  over 
it  in  front  the  callosal  marginal  convolutions  superimposed 
and  the  centrum  ovale  majus  coming  into  view  as  we  cut 
away,  on  a  parallel  line,  the  convex  gray  cortex  convolu- 
tion area,  including  so  many  of  the  motor  centers  above,  and 
into  which  corpus  callosum,  we  made  Hogarth's  line  of 
grace  and  beauty,  and  brought  into  view  those  wonderful 
centers  of  the  brain,  the  lateral  ventricles,  in  which  we  saw 
the  great  basal  ganglion,  the  tenia  semilunaris,  the  cornua 
ammones,  the  pillars  of  the  fornix,  the  fornix  itself  and  the 
tela  choroidea,  the  velum  interpositum  and  between  the  lateral 
ventricles  the  fifth  ventricle,  away  anterior,  and  intermediate 
the  third,  with  its  three  commissures,  downward  and  posterior 
the  fourth  ventricle  and  between  the  fourth  and  third  that 
it  en  with  the  long  name  a  tertio  ad  quartum  veniriculnm,  and 
the- cerebellum  above  and  behind  the  medulla  after  we  had  cut 
away  and  lifted  up  the  whole  corpus  callosum  as  I  have 
done  today. 

These  commissures  are  connections  and  are  called  com- 
missural or  connection  fibers,  but  the  brain  has  others 
which  are  especially  called  association  fibers.  They  are 
similar  to  what  you  are  familiar  with  in  some  of  your 
plates  showing  the  corona  radiata.  Some  of  them  are  dis- 
cernable  with  the  naked  eye  or  a  pocket  lense,  others 
are  more  or  less  microscopic,  just  as  some  of  the  fibers  of 
the  internal    capsule  are,  though    you  may  discern    them    in 


39 

the  aggregate.  They  connect  convolutions  and  areas  of  the 
brain,  fronto-occipital,  fronto-temporal  and  occipito-lateral 
and  nearby  convolutions. 

This  great  family  of  neurones  compacted  into  brain 
mass  and  lying  in  close  proximity  to  each  other  in  contig- 
uous neighborhoods  occupying  so  much  territory,  must  have 
means  of  communication.  These  the  cerebro-physiologists 
have  named  after  Fleschig,  projection  tracts,  and  they  must 
have  centers  for  collecting,  coordinating  and  elaborating  im- 
pressions conveyed  to  them  by  the  association  tracts  and 
these  centers  are  called  association  centers.  In  the  conscious 
intellectual  or  psychic  areas  of  the  brain  the  process  is  called 
ideation,  reflection,  ratiocination,  cerebration,  thought,  con- 
ception, etc.  When  this  association,  elaboration  and  coordi- 
nation takes  place  unconsciously",  the  process  is  called 
cerebral  automatism,  as  in  sleep, dreams, and  if  accompanied  by 
sleepwalking,  somnambulism,  or  if  done  by  the  will  of  another, 
hypotism  or  somnavolism  as  I  have  termed  it,  which  I  have 
defined  to  be  an  absence  of  the  normal  will  by  induced 
sleep.  Learned  psychologists  speak  of  these  states  as 
states  of  subliminal  consciousness.  If  it  takes  place  in  the 
course  of  a  fever  or  a  toxic  state  of  the  blood  or  of  a  dis- 
ease involving  the  integrity  of  the  psychic  neurones  and 
their  power  of  normal  association,  the  condition  is  called 
delirium  or  insanity.  If  the  function  of  the  association  centers 
is  overwhelmingly,  completely  suspended  suddenly,  it  is  psy- 
chic or  cerebral  shock,  coma,  etc.  If  crippled  in  speech  area, 
it  is  called  aphasia,  if  temporarily  suspended  in  sight  area,  it 
is  called  psychic  blindness,  mind  blindness,  selinblindheii ,  the 
mind  or  soul  blind  disease.  If  certain  other  psychic  perver- 
sions appear  as  shown  by  alternate  emotional  states  such  as 
laughing  and  crying,  visions, especially  of  eroto-illusional  kind 
and  moral  perversions,  we  are  likely  to  have  hysteria.     If  the 


40 

coordinations  are  markedly  above  normal,  we  suspect  par- 
esis or  if  far  below  it  melancholia.  These  tracts  are  the  tela- 
psychica  or  chorda  mentes  or  tracts  of  the  mind  and  these 
centers  might  be  called  the  puncta  mentes  or  centers  of 
mind,  or  psychic  centers  or  centers  of  mental  action.  If 
the  locus  minoris  resistentia  is  under  stress  of  morbific  influ- 
ence and  we  have  the  neuropathic  diathesis  or  constitution 
pre-existing,  that  is,  the  tendency  of  the  psychic  neurones  to 
act  abnormally  under  psychic  stress  and  haemotoxines,  the 
strained  brain  may  give  way  to  insanity  or  delirium  in  some 
form.  If  the  strain  is  in  the  psycho- motor  area  or  motor 
tracts  of  the  brain  and  the  punctum  minoris  resistentia  is  on 
this  part  of  the  cerebrum — either  in  these  centers  and  motor 
tracts  of  the  brain,  we  may  have  paralysis  or  paralytic 
insanity  or  Jacksonian  or  grand  mal  epilepsy,  that  is,  epi- 
lepsy with  limited  or  general  motor  or  convulsive  manifesta- 
tions, on  some  form  of  cerebral  tremor  of  cerebral  origin. 

NEURONES  GROUPED  AS  NERVE  CENTERS. 

The  neurones  of  the  brain,  the  spinal  cord  and  the 
ganglia  of  the  sympathetic  system,  are  assembled  together  in 
groups  of  action  or  communities  of  interest,  for  purposes  of 
sensation,  motion  and  mental  impression  or  action,  groups  of 
control  or  inhibition  or  restraint,  sensation,  mentality  and 
emotion.  These  groups  are  called  sensory,  motor,  or  psychic 
neurone  centers.  Thus  we  describe  the  cillio  spinal  center  of 
the  cervical  or  neck  enlargement  of  the  spinal  cord  which 
influences  the  widening  of  the  pupil  opposing  its  sixth 
nerve  contracting  influence,  and  which  disturbs  the  pupil 
when  a  violent  blow  is  received  in  the  back  of  the  neck,  a 
blow  pugilists  guard  against,  as  they  do  blows  below  the  belt 
where  the  semi- lunar  ganglion  and  solar  plexus  are.  In 
this  region  also  are  the  cervical    vaso- motor  centers    of    the 


41 

sympathetic  system  which,  when  paralyzed,  permit  dilations 
of  the  brain's  blood  circulation  vessels  and  cause  cerebral 
congestion  or  fullness  of  blood  in  the  head  to  follow,  or 
when  irritated  only  contract  and  cause  facial  and  cerebral 
pallor. 

We  have  also  the  psychic  centers  of  intellection,  emo- 
tion and  expression  in  the  brain,  like  the  speech  center  of 
Broca  in  the  posterior  aspect  of  the  third  left  frontal  con- 
volution, the  psycho-motor  centers  on  either  side  of  the 
fissure  of  Rolando,  the  sensory  centers  of  the  cord,  such  as 
are  involved  in  posterior  spinal  sclerosis  which  causes  the 
patient  to  appear  paralyzed,  when  he  is  not,  and  the  motor 
cord  centers  of  the  anterior  horns  such  as  are  involved  in 
polio  myelitis  anterior  or  the  essential  paralysis  of  children. 

Then  there  are  the  auditory  centers  concerned  in  hear- 
ing naturally  located  in  the  temporal  region  and  the 
olfactory  or  smelling  centers  singularly  placed  in  the 
tempero-sphenoidal  region  instead  of  at  the  point  of  origin  of 
olfactory  nerves  from  its  bulb  and  the  perforated  space  and 
the  under  surface  of  the  middle  lobe  of  the  brain,  and  the 
sight  centers  away  back  in  the  occipital  lobes,  as  you  may 
have  discovered  by  the  flash  of  light  you  saw  when  you  fell 
backward  and  struck  your  occiput  on  the  ice  when  skating 
in  those  happy  days  of  boyhood,  not  so  far  away  from 
you  in  memory  as  from  me,  but  perhaps  no  less  mentally 
vivid  in  me.  The  sight  centers,  diagnostically  considered, 
are  also  in  the  corpora  quadrigemina,  the  angular  gyri 
and  all  along  the  optic  tracts,  a  fact  which  will  aid  you  in 
focal  diagnosis  of  brain  lesions.  Then  there  are  the  centers 
of  taste,  facial  sensation  and  motion  and  of  the  great  vagus 
nerve  going  to  the  heart,  lungs,  stomach,  etc.,  in  the 
fourth  ventrical,  medulla  oblongata  region  within  the  cranium. 

Neurones  change  under  touch  of    disease    and  the   con- 


42 

sequent  symptomatic  changes  they  will  reveal  to  you  in  the 
functions  of  organs  whose  movements  they  inaugurate  and 
regulate,  cither  singly  or  as  syndicates  of  neurone  action 
organized  into  nerve  centers,  will  enlist  your  hest  powers  of 
observation  and  thought  in  practice  to  climb  and  later,  a 
knowledge  of  them  will  help  you  to  soar  above  the  common 
herd  in  medicine.  Fail  not,  therefore,  to  appreciate  the  im- 
portance of  a  study  of  the  neurones.  They  are  matters 
infinitely  minute  to  your  vision  but  yet  magnificently  grand 
for  you  to  consider.  Their  study  will  lead  you,  like  Provi- 
dence does  all  of  us,  in  ways  for  the  welfare  of  mankind 
which  as  yet  may  be  "we  know  not  of." 

NEURONES  GROUPED  AS  NERVE  CENTERS. 
FIG.    12. 


— (.'■  gangliou  of  a  calf. 

Neurons  ;    (hb)  netiraxons  ;      (c)  neurodeodritea  ;    (d) 
varieose  nerve  ni.iils.CVVW'^^crV^ 


ASSOCIATION   FIBERS    OF  THE   BRAIN. 
FIG.    13. 

x  x  '  SI/.** 


(d'apres  Meynert).  —  Fibres  d' association,  —  Coupe  verticale  et  antero- 
posie"rieui'e  du  ccrvcau  du  ccrcoccbus  cynomolgus. 

F,  extremite  frontale  ;  —  0,  extremite  occipitalc;  —  H,  conic  d'Ammon;  — 
RR,  substance  grise  certicale;  —  SH,  sillon  de  l'hippocampe;  .  -44,  troisiemc 
segment  du  noyau  lenticulaire;  —  GT,  avant-mur ;  —  Cs,  queue  du  corps  strie  ; 
—  P,  pulvinar; —  corps  genouille  extenie; —  pv,  fibres  propres  unissant  deux 
circonvolutions  ;  ^~  arc,  (asciculus  arcuatus  ;  —  vnc,  fasciculus  uncinatus  ;  —  Ig, 
faisceau  longitudinal  inferieur;  —  C«,  commissure  anterieure;  —  inf,  corne  pos- 
terieure  des  ventricules  lateraux. 

Antero-posterior  ventrical  section  the  brain  of  {cercocehus  cynomolgus) 
a  long-tailed  ape,  after  Meynert.  F,  frontal;  O,  occipital;  H,  cornu 
Ammonis;  R,  R,  cortical  gray  matter;  SH,  hippocampus;  P,  pulvinar; 
Gt,  outer  wall;  Pv,  fiber  propriae  connecting  adjacent  convolutions  of  the 
cortex;  Gs,  tail  of  corpus  striatum;  arc,  arcuate  fibers;  unc,  uncinate 
fibers;    Lg,  inferior  longitudinal  fibers;    Ga,  anterior  commissure. 


RELATION   "I     IMPORTANT   BRAIN    REGIONS  AND  PROJECTION 

\\T>  ASSOCIATION   FIBERS. 

FIG.   14. 


m 


BAUOUftrau. 


—  Cctte  figure  est  empruntee  a  l'ouvragc  do  M.  Meynerl  (  Stiickcr't 
Hamii/ucli,  t.  If,  p.  72J,  fig.  213).  Ellc  rcpn'sente  unc  coupe longiludinalcct  hori- 
zonlnlc  dc_  ],i  moitie  g-iuche  du  ccrveau  du  rcrcoccbus  cyno     ilgus. 

F.  extremitd  frontale;  —  0,  reyion  occipitale;  —  PT,  enfrec  de  la  scissurc  do 
kiylvius  ;  —  I,  insula  ;  —  CI,  nvanl-mur;  —  T,  corps  calleux  ;  —  S,  septum  ;  — 
O,  commissure  ant  epicure. 

A,  conic  d'Ammon;  —  V,  corne  anlericure  du  ycntriculc  lateral;  —  \p,  cornc 
posterieuic  ;  —  Vw,  ventriculc  du  moyen.  —  Cm,  commissure  moyenne.  —  Aq, 
aqneduc. 

Li,  Lit,  Liu,  segments  du  noyau  lcnticulairc  ;  —  Na,  tele,  ei  Nc  queue  du 
noyau  caude. 

Th,  partiedela  coiiche  optiquesitueeenavant  des  corps genouilles;  —  T/i'couche 
opiique,  Pulvinar. 


Longitudinal  horizontal  section  of  left  half  of  brain  of  long-tailed  ape, 
after  Meynert,  Strieker's  Handbook.  F,  frontal;  O,  occipital  region;  FS, 
fissure  of  Sylvius;  I,  insula  or  island  of  Reil;  CI,  outer  region  of  external 
and  internal  capsule  and  claustrum;  LI,  LII,  Llll,  segments  of  cuticular 
nucleus;  T,  corpus  callosum,  anterior  border;  S,  line  of  septum- lucidum 
enclosing  the  fifth  ventricle;  V,  anterior  horn  of  lateral  ventricle  with  S, 
the  line  of  the  septum  lucidum  between  it  and  its  opposite  lateral  ventricle, 
not  shown  in  this  cut;  VP,  posterior  horn  of  lateral  ventricle;  Nc,  head, 
Na,  foot  or  tail  of  caudate  nucleus;  B,  Bs,  Bi,  cerebral  peduncle;  Gi  and 
Ge,  internal  and  external  knees  of  the  corpus  striatum;  Th,  optic  bed  or 
thalamus;  Th',  pulvinar  of  optic  thalamus;  Qu,  corpora  quadrigemina; 
Ap,  aqueduct  of  Sylvius  from  third  to  fourth  ventricles;  Vm,  middle  or  third 
ventricle;  cm,  middle  commissure;  Om,  medullary  fibers  from  occipital 
lobes  to  pulvinar  and  knees  of  internal  capsule;  M,  ms,  other  medullary 
fibers;     R,  occipital  cortex. 


FIG.   15. 


FIG.   16. 


FIG.   IS. 


FIG.   17. 


The  illustration,  Fig.  16,  is  a  neuroglia  cell  showing  dendritic  branching 
and  mossiness  of  its  processes.  From  the  white  brain  matter  of  sheep. 
This  form  is  common  in  growing  brains.  It  is  to  be  regarded  as  a  neuroglia 
cell  that  has  not  yet  reached  full  development.  Fig.  15  is  a  large  neuroglia 
cell  attached  to  vessel  wall.  From  the  white  matter  of  brain  of  sheep. 
Most  of  the  processes  show  no  branching.  This  is  the  typical  form  of  the 
fully  developed  neuroglia  cell.     (After  Ford  Robertson.) 

Fig.  17  shows  a  pyramidal  cell  from  the  cerebral  cortex  with  the  nucleus 
and  nucleolus,  while  immediately  to  the  left  (Fig.  18)  is  shown  neuroglia 
cells  of  the  Golgi  type,  after  Kolliker. 


NEURONES,   EPITHELIAL  CELLS   AND   NEUROGLIA 
FIG.    19. 


FIG.  20. 

Description  over. 


The  upper  illustration  (Fig. 19)  shows  ganglion  cells  or  neurones,  A  and 
B,  alter  Ranvier-.  C  are  neuroglia  cells,  Spider  or  Dieter's  cells;  D  is  an 
axis  cylinder  process  or  neuraxone;  P  are  protoplasmic  processes.  All 
from  the  spinal  cord. 

The  lower  illustration  (Fig.  20)  shows  epithelium  and  neuroglia  sur- 
rounding the  central  canal,  section  through  the  spinal  cord  of  a  human  em- 
bryo of  twenty-three  centimeters  length.     (After  Lenhossek). 

Neuroglia  is  a  peculiar  tissue.  It  belongs  exclusively  to  the  central 
nervous  system  and  the  optic  nerves.  It  is  a  patching,  making  patchwork 
connections  for  damaged  nerve  connections,  as  well  as  being  a  neurone- sup- 
porting network  tissue  or  scaffolding.  It  not  only  does  the  work  of  glue,  as 
its  Greek  name  indicates,  between  the  neurones,  scaffolding  and  holding  them 
in  their  proper  relations,  as  I  have  already  said,  but  it  acts  as  a  sort  of 
plug  for  stopping  neural  holes.     The  neuroglia  is  often  simply  called    glia. 

"Wherever  in  the  central  nervous  system  nerve  substance  degenerates 
from  disease,  the  glia  (neuroglia)  appropriates  the  empty  space.  The  re- 
placement with  glia  has  a  limit  only  where  its  elements  are  destroyed  along 
with  the  nerve  substance  and  where  its  power  of  growth  is  not  sufficient  to 
rill  up  the  large  deficit. 

"The  central  canal  and  the  ventricles  send  long  processes  into  the 
nerve  substance.  In  man  these  reach  the  external  surface  only  in  a  few 
places.  These  fibers  as  in  the  figure  above  belong  naturally  to  the  sup- 
porting tissues. 

"The  neuroglia  net  differs  somewhat  in  different  parts  of  the  central 
nervous  system  and  forms  here  and  there  dense  accumulatious  in  parts 
quite  devoid  of  nerve  substance.  Thus,  a  thick  layer  of  nearly  pure  con- 
nective tissue  covers  the  whole  surface  of  the  brain  and  cord  and  extends  a 
short  distance  along  the  nerve  roots  in  the  form  of  a  plug.  In  the  same 
way  there  is  found  on  the  inner  surface  of  the  central  nervous  system  just 
under  the  epithelium  an  especially  rich  development  of  neuroglia.  The  net 
work  in  the  gray  substance  is  in  some  parts  denser,  in  others  less  dense, 
than  in  the  white  substance.  The  large  nerve  cells  are  frequently  so  en- 
circled that  they  appear  to  lie  in  a  fine-meshed  basket."— Edinger. 


GROUP  OF  NEURONES   MAKING   NERVE  CENTERS. 
FIG.    21. 


' 


i 


•\  ~;avm*    x    *r. 


?  * 


>~ 


-Pyramidal  cells  from  the  frontoparietal  region  of  a 
cat's  feeing  at  term.     {\  obi.,  no  eye-piece.) 


FIG    22. 

The  Association  Fibers 


Co  xvvoVw- 


AtVo«v%j     a.     VicoioXo- oe<V^'vK"-\  ^'vXoars^     C  -  Cv«,^u.Xi 
or     Y*owvAo-\e>r*\.'yoxo-V>  '•V>*S'  <*-  V»*.\X   o/vou-wj   -<\ve    u-y^et 
bur^occ    o^  cof^wfe  c«.\\o4i<.y<»^    Jj.  IX inc'iyx-oXe. ,ot   VvooV- 

ZLO;OT.     W"»*X  ce»«^\uu.      F.F.F.       CeroVaTO-L    oot<ck. 


CHAPTER  IV. 

THE  NEURONE  CONTINUED;     ITS   EFFERENT   PROLONGATION   OR  PROLIF- 
ERATIONS.    THE  AXONE,  NEURAXONE,  NEURITE  OR  AXIS-CYLINDER 
PROCESS;     THE  NERVE  CELL  AND  ITS  BELONGINGS.      HISTO- 
LOGICAL  COMPOSITION    OF    NERVE    CENTERS.        THE 
NEURONE    AND    ITS     DENDRITES    OR    AFFERENT 
CELL   PROCESSES.      THE   NEUROGLIA.* 


In  the  preceding  lectures  we  have  endeavored  to  fix 
in  your  minds  the  idea  of  the  neurone  as  a  nerve  center 
unit  of  impression,  elaboration  and  expression.  A  unit 
of  action,  a  unit  of  independent,  yet  of  communicative  ac- 
tion, impressed  i:  e.,  receiving  impressions  from  other 
neurones,  acting  upon  those  impressions  and  sending  out 
other  impressions  to  neighboring  neurones  or  receiving  im- 
pressions from  the  blood  or  from  the  periphery  or  from 
environment  and  of  making  impressions  on  circulation  and 
viscera  and  of  extracting  nutrition  from  the  blood. 

The  neurones  are  composed  of  nuclear  centers  and  nerve 
fibers.  They  are  the  nerve  cells  and  their  belongings  con- 
sidered as  independent  units  of  impression  and  action.  They 
are  nourished  by  vessels  and  have  vessels  coming  from  them 
as  you  may  see  in  some  of  Golgi's  demonstrations  and  have  a 
microscopic  lymph  about  them  which  you  will  better  under- 
stand as  you  advance  in  the  study  of  neuro-histology.  This 
lymph,  which    is  essentially    a    cerebro-spinal  fluid,    bathes 

*See  preceding  and  following  illustrations. 

[43] 


44 

them  as  the  brain  is  bathed  in  subarachnoid  and  ventricular 
fluid  and  as  the  spinal  cord  swims,  like  a  pickle  suspended 
from  the  neck  of  a  jar,  in  cerebrospinal  fluid  or  like  myriads 
of  fish  living  in  a  vase  scantily  filled  with  water.  The  nerve 
center  cells  and  their  belongings  make  up  the  neurones.  They 
live  and  move  and  have  their  being,  so  to  speak,  in  a  san- 
guino-aqueous  medium, their  life  pabulum  is  sanguino-serous 
and  the  blood  is  the  final  and  ultimate  life  thereof,  as  they 
in  turn  may  be  the  life  or  death  of  the  blood  through  physical 
or  psychical  nerve  center  shock  and  influences,  exaltation  or 
depression  of  nerve  centers,  on  the  metabolisms  of  the  body. 
The  neurones  have  sources  of  supply  and  waste,  nutrient 
blood  vessels,  etc.,  and  supporting  tissues  to  keep  them  in 
relative  and  normal  position,  shape,  etc.  These  tissues  are 
called  neuroglia  or  Dieter's  cells,  connective  tissue,  etc.  The 
neuroglia  is  what  its  name  implies — a  neurone  glue  (vevpov,  a 
nerve  and  y^*-,  glue),  that  delicate  connective  tissue  frame- 
work which  supports  the  nervous  matter  and  blood  vessels  of 
the  brain  and  spinal  cord,  etc.,  and  holds  them  and  the 
neurones  in  their  proper  places.  The  neuroglia  has  been 
named  from  this  supposed  function,  but  let  me  tell  you  now 
so  that  you  may  not  think  that  you  know  it  all,  from  what  1 
say  in  these  brief  lectures,  that  other  and  more  important 
functions  have  been  lately  ascribed  to  the  neuroglia,  that  tend 
to  give  them  a  higher  dignity  in  the  cerebro-spinal  axis 
than  mere  scaffoldings  of  vessels  and  nerve  cells,  but  as  1 
shall  not  examine  you  on  this  subject  1  will  not  ask  you  to 
carry  in  your  already  fully  burdened  cerebral-cortex  neu- 
rones, more  neurology  than  you  will  be  asked  to  exhibit  in 
the  green  room  at  your  final  examination.  Your  psychic 
neurones  will  be  tired  enough  at  the  end  of  the  session 
and  1  will  not  overburden  them  with  all  we  teachers  know 
or  think  we  know  on  the  subject,  lest    you  might  have,  at 


45 

the  end  of  the  curriculum,  too  much  neurasthenia  involving 
your  cerebral  neurones,  (cerebrasthenia,)  to  unburden  your- 
selves with  credit,  for  a  tired  psychic  neurone  does  not  do 
itself  justice  under  mental  strain.  It  needs  rest,  recreation, 
retraction,  sleep.  After  prolonged  exercise  the  tired 
neurone  is  neuratrophic  and  needs  a  chance  for  re- 
pair and  recuperation.  Prod  it  under  these  circumstances 
and  it  may  act  unstably  and  not  to  the  best  interest  of  the 
brain  that  owns  it.  Take  good  and  tender  care  of  your  psychic 
neurones  during  the  course  of  work  before  you.  You  are 
in  the  arena  of  supremest  effort,  and  the  neurones  of  every 
one  of  the  five  or  six  layers  of  your  gray  matter  will  require 
all  the  aid  of  sleep  and  exercise  and  rest  and  ample  food  and 
abstention  from  vicious  habits,  long  study  hours  and  worry 
that  rob  you  of  rest  and  repair,  that  you  can  give  them. 

Do  not  imagine  from  the  block  demonstration  I  have 
given  you  of  the  action  of  one  neurone  upon  another  that 
each  neurone  bodily  falls  upon  another.  The  blocks  in  a 
row  were  only  produced  to  show  how  the  impulse  of  one  might 
be  communicated  to  another,  for  the  neurones  have  prolonga- 
tions for  communicating  purposes.  These  proliferations  touch 
other  neurones  but  do  not  interlace  with  them,  as  was  until 
lately  taught.  They  come  in  contact,  but  do  not  intertwine 
with  their  neighbors,  they  touch  but  do  not  mix.  They  com- 
municate by  means  of  neuraxones  and  dendrites  as  you  gen- 
tlemen do  with  each  other,  with  your  arms  and  hands.  The 
long  communicating  arm  of  the  neurone  is  called  the  neu- 
raxone  or  neurite,  formerly  axis  cylinder.  The  dendrites  are 
the  short  receiving  arms  of  the  neurone.  One  neurite  is  an 
efferent  or  outgoing  process,  carrying  out  impressions  (from 
the  Latin,  ferre,  to  carry,  and  ex,  out.  of,)  the  other  is  an 
afferent  prolongation  carrying  impressions  to  the  neurone 
(from  ferre  meaning  to  carry,  and  ad,  to). 


46 

The  axis  cylinder,  or  axis  cylinder  process,  is  the  most 
familiar  and  longest  used  term  and  writers  still  speak  of  the 
cell  and  axis  cylinder  process,  the  two  together  making,  with 
the  dendrites,  the  neurone  and  glia  cells  between.  The 
ganglion  cell  with  its  nucleus  and  nucleolus,  neuraxon  and 
dendrite,  make  the  neurone.  Neurones  are  a  physiological 
developmental  unit,  standing  isolated  but  yet  grouped  to- 
gether, as  1  have  said,  touching  their  neighbor  neurones 
physiologically  or  pathologically  in  health  or  disease,  and 
passing  on  to  each  other  healthy  or  unhealthy  impressions. 
Take  care  of  your  neurones  and  the  neurones  of  your  patients 
as  you  would  take  care  of  your  characters  and  purses 
and  the  good  name  of  this  college.  Take  good  care  of  the 
tone  of  your  neurones  and  they  will  take  good  care  of  you. 

The  independent  individuality  of  the  neurone,  notwith- 
standing its  dependence  upon  others  in  the  same  nerve 
center  grouping,  is  proved  by  the  well -observed  facts  of  both 
experimental  and  morbid  pathology,  that  the  effect  of  its 
disease  or  injury  are  so  often  found  circumscribed  to  the 
diseased  or  injured  body  of  the  neurone  and  its  processes. 
If  the  axis  cylinder  of  a  peripheral  nerve  or  the  neuraxon  of 
a  central  neurone  (the  same  thing),  be  studied  under  the 
influence  of  mechanically  induced  disease,  its  diseased  condi- 
tion will  reflect  the  disease  of  the  central  source  in  the  gan- 
glion cell  or  neurone.  The  life  or  health  of  all  parts  of  the 
neurone  depends  on  the  health  or  integrity  of  its  body,  mainly 
the  nucleus.  If  this  is  diseased  the  remainder  degenerates 
or  dies.  Neither  the  neuraxones  nor  dendrites  can  live 
independently  of  the  neurone  body  whence  they  arise,  any 
more  than  our  limbs  might  live  without  an  attached  body. 
The  reverse  also  takes  place  but  not  so  markedly  or  so 
rapidly.  Diseased  processes  in  neuraxones  or  dendrites  will 
sooner  or  later    and    more  or    less    involve  the  body  of    the 


47 

neurone    whence  they    arise    just  as    a  disease  of  the  hand 
may  spread  to  the  body. 

The  following  experiment  with  contiguous,  rocking,  not 
falling  blocks  made  secure  so  that  they  may  move  back  and 
forth  and  expand  and  contract  without  falling  down,  and 
supplied  with  projections  to  represent  the  neurites  and  den- 
drites, may  serve  to  make  plainer  the  method  of  movement 
of  the  neurones  in  your  anatomies. 

Now  let  a  few  of  the  students  come  down  into  the 
amphitheatre  and  stand  near  enough  to  touch  each  other 
with  elbows  akimbo  on  one  side  and  arms  outstretched  on 
the  other,  the  long  outstretched  arm  and  hand  representing 
the  long  axis  cylinder  or  neurite  or  neuraxone,  the  short  pro- 
jecting elbow  akimbo  representing  the  dendrite  and  you 
have  the  neurone  theory  of  Ramon  y  Cajal  illustrated,  and 
vitalized  so  that  1  hope  you  may  not  forget  it,  but  do  not 
keep  up  the  illustration  any  longer  than  may  be  necessary 
to  impress  it  on  your  respective  psychic  neurones,  or  you 
may  make  a  bad  neuritic  impression  through  my  psycho- 
neural  dendrites  on  my  psychic  neurones. 

fig.  23. 


Cell  or  5j.in.il  ganglion  of  normal  -log.     L< 


TMonin.    ligaro  .••  .-*■ 


FIG.   24. 


ineu.wfctfs    Projector*.  Susfcm  o  ?  IVvr.  ft  *cx\.«v  aVvowiaa^vVsaca 


l<5 


I,  Scheme  of  the  brain. — C,  C,  cortex  cerebri;  C.s,  corpus  striatum,  NV,  nucleus  lenticularis; 
T.o,  optic  thalamus;  v,  corpora  quadrigemina ;  P,  pedunculus  cerebri;  H,  tegmentum; 
and  /,  crusta;  I,  I,  corona  radiata  of  the  corpus  striatum;  2,  2,  of  the  lenticular  nucleus; 
3,  3,  of  the  optic  thalamus;  4,  4,  of  the  corpora  quadrigemina;  5,  pyramidal  fibres  from 
the  cortex  cerebri  [Ftechsig)  ;  6,  6,  fibres  from  the  corpora  quadrigemina  to  the  tegmentum  ; 
in,  further  course  of  these  fibres;  8,  8,  fibres  from  the  corpus  striatum  and  lenticular  nucleus 
to  the  crusta  of  the  pedunculus  cerebri;  M,  further  course  of  these;  S,  S,  course  of  the 
sensory  fibres;  R,  transverse  section  of  the  spinal  cord  ;  i>.  \V,  anterior,  and  h.  W,  posterior 
roots;  a,  a,  association  system  of  fibres;  <-,  c,  commissural  fibres.  II,  Transverse  section 
through  the  posterior  pair  of  the  corpora  quadrigemina  and  the  pedunculi  cerebri  of  man 
— /,  crusta  of  the  peduncle ;  s,  substantia  nigra  ;  v,  corpora  quadrigemina,  with  a  section 
of  the  aqueduct.     Ill,  The  same  of  the  dog  ;  IV,  of  an  ape  ;  V,  of  the  guinea-pig. 


FIG.  25. 


-Wurzburg  Golgi  preparation.  Cell 
from  the  cervical  .sympathetic  in  a  calf. 
(a)  The  neuron  ;  (A)  the  neuraxon:  (c 
neurodendrites    ' 


"  ,  \<>)  me  neuraxon:  (c 
■  (VVV<yv\AfrvVJ 


CHAPTER    V. 

OUTLINE   FORMS  AND  FUNCTIONS  OF  NEURONES.      POLAR  AND 
APOLAR,   BI-POLAR  AND  MULTI-POLAR  NEURONES. 


NEURONE  AND  NERVE   CELL;    SYNONYMOUS    IN  A  BROAD  SENSE.      DISEASE 
CHANGES   IN   THE   NEURONES. 

The  neurone  is  a  microscopic  mass  of  finely  granular 
protoplasm  surrounding  a  nucleus,  this  nucleus  including  a 
nucleolus,  sends  out  prolongations  or  proliferations  which 
are  called  poles.  Some  neurones  have  none  of  these  poles 
and  are  hence  called  apolar  neurones;  i.  e.,  without 
poles.  Others  are  numerically  designated  as  uni-polar  or 
mono-polar,  one  poled;  bi-polar,  two  poled;  and  if  possess- 
ing three  poles  or  more,  multi-polar  or  many  poled  neurones. 
Tht-  neuraxone,  neurite  or  axis  cylinder  process,  all  meaning 
the  same  thing,  proceeds  outward  as  one  of  these  poles.  It 
is  an  efferent  prolongation  designated  to  carry  out  the  nerve 
energy  elaborated  and  stored  in  the  neurones  and  commun- 
icate the  neurone's  energy  to  a  neighboring  neurone  or 
elsewhere.  It  acts  upon  impressions  received  from  other 
neurones,  changes  them,  as  in  reflex  neurone  centers,  into 
motor  impulses,  modifies  impulses  and  impressions  and 
elaborates  and  originates  new  impressions  to  be  sent  out 
along  the  neuraxone.  This  is  something  of  a  repetition  but 
it  is  important  for  you  to  remember  it. 

The  Greek   term  kvVos,  and    the  Latin  cella,  both    mean 

[48] 


49 

a  chamber,  and  in  these  littje  neural  chambers  of  the  brain 
for  instance,  wondrous  movements  go  on  and  mighty  though 
silent  and  inobtrusive  forces  reside.  In  the  little  neurone 
chambers  of  the  gray  cortex  dwell  psychical  tenements 
which  manifest  to  us  the  mind  and  soul  of  man.  You  must 
be  mindful  of  them — these  psychic  central  neurones.  The 
manner  in  which  you  impress  them  in  practice  and  the 
effect  of  disease  on  them  will  help  or  harm  your  patient 
and  make  or  mar  your  professional  careers. 

The  terms  cell  and  neurone  are  yet  often  used  by 
writers  in  a  synonymous  sense,  they  meaning  to  include  in 
the  term  cell  as  thus  substitutionally  employed  for  neurones, 
all  of  the  already  described  constituents  of  the  cell,  which 
make  the  nerve  unit  or  neurone.  Thus  Barker*  in  discussing 
the  cells  of  the  human  cortex,  meaning  thereby  the  neurones, 
for  he  is  speaking  of  the  neurone  as  a  unit,  quotes  from 
the  indefatigable  and  brilliant  Franz  Nissl,  an  authority  you 
will  bye  and  bye  become  more  familiar  with  and  much 
more  interested  in  than  you  are  now,  for  he  is  the  author 
of  Nissl's  stain  and  has  made  many  great  and  valuable 
contributions  to  our  knowledge  of  the  anatomy  and  pathology 
of  the  neurones,  who  in  a  recent  paper  ("Nervencellen 
und  grau  Substanz,"  Miienchener  Medinische  Wochenschrift , 
1893,  a  great  German  medical  journal  which  will  much  in- 
terest you  who  read  German)  distinguishes  seven  forms 
of  alteration  in  the  cells  of  the  human  cortex,  viz.,  acute 
and  chronic  cell  disease,  combined  disease  forms,  severe  cell 
disease,  vanishing  of  cells,  simple  tumefaction  and  granular 
breaking  up  of  cells.  Barker  goes  on  to  tell  us,  and  you 
must  consult  Barker's  great  book  when  you  have  time  to 
pursue  the  subject  at  your  leisure,  that  Nissl  lays  much 
emphasis  on  the  first  of  these    forms,    the    so-called    acute 

*Barker,  Nervous  System,  p.  291. 


50 

cell  disease.  According  to  him  it  runs  the  same  course  in 
every  instance,  having  always  the  same  termination,  and 
when  it  has  once  appeared  it  involves  all  the  cells  of 
the    cortex     without     exception.      The     changes     arc      so 

characteristic  that  after  once  seeing  them,  one  can  make  a 
positive  diagnosis  without  difficulty.  The  disease  does  not 
affect  a  part  of  the  cell  only,  but  involves  the  whole 
neurone,  the  stainable  as  well  as  the  unstainable  substance, 
the  nucleus  as  well  as  the  cell  body,  the  axone  as  well  as 
the  dendrites,  all  parts  being  involved  apparently  in  the  same 
degree.  In  this  form  of  neurone  change  the  unstainable 
substances  are  so  altered  that  they  become  stainable,  a  fact 
that  makes  Nissl  think'  that  his  "unstainable  substance" 
consists  not  only  of  a  fibrillary  constituent,  but  in  addition, 
of  one  or  several  other  substances. 

Nissl  finds  this  acute  cell  disease  not  only  in  acute 
paralyses  but  in  a  great  variety  of  psychoses,  and  also  in 
patients  who  have  not  been  the  subjects  of  mental  disease 
in  the  ordinary  sense,  but  who,  succumbing  to  various  dis- 
orders, have  before  death  been  partly  delirious,  partly 
somnolent.  The  involving  of  all  the  cells  in  the  cortex  is 
an  exceedingly  interesting  feature,  and  one  met  with  rarely 
in  any  other  form  of  disease.  All  the  psychic  cortex  neu- 
rones are  more  or  less  involved  in  delirium  and  the  delirious 
forms  of  insanity. 

An  instructive  paper  dealing  with  the  alteration  dis- 
coverable by  Nissl's  method  in  the  human  cortex  and  also 
quoted  by  Barker  is  that  of  August  Hoch  (Nerve  Cell  Changes 
in  Somatic  Diseases)  of  the  McLean  Hospital,  of  Waverly, 
Mass.  Working  in  Nissl's  laboratory  at  Heidelberg,  Hoch 
had  been  impressed  with  the  frequency  with  which  changes 
had  been  found  in  the  cortical  cells  of  individuals  dead  of 
diseases  of    different    kinds.      Recognizing  the  importance  of 


51 

a  thorough  knowledge  of  the  possible  changes  '  in  the  cells 
in  somatic  disease  for  the  interpretations  of  the  pathological 
alterations  met  with  in  the  brains  of  the  insane,  Hoch 
directed  his  special  attention  toward  these.  In  the  paper 
mentioned  he  deals  with  a  particular  cell  alteration  which 
he  designates  as  "cell  shrinkage."  He  has  studied  this 
change  in  human  beings,  in  whom  it  occurs  in  the  most 
diverse  diseases,  and  also  in  experimental  animals. 

This  alteration  of  the  cells,  as  he  describes  it,  is  found 
chiefly  in  the  medium  and  smaller  sized  pyramids,  as  well 
as  in  the  cells  of  the  fifth  layer.  The  contour  of  the 
neurone  is  distorted  and  shrunken,  and  there  may  be  much 
retraction  of  the  borders  of  the  cell  body  between  the  pro- 
cesses, so  that  a  part  of  the  cell  body  may,  at  first  sight, 
look  like  a  part  of  a  cell  process.  A  well  marked  honey- 
comb is  visible  in  the  cell  body,  and  is  sometimes  indicated 
in  the  processes.  The  nucleus  is  darkly  stained,  diminished 
in  size,  and  is  often  distorted.  In  Nissl  preparations  it  looks 
homogeneous;  the  nucleus  is  often  oval  in  shape,  and  may 
be  paler  than  normal,  but  never  shows  a  purplish  hue. 
Instead  of  the  honeycomb  appearance  the  protoplasm  may 
be  "crumbly  looking."  But  I  cannot  go  on  discussing  in 
minutae  this  interesting  subject.  You  will  not  be  expected 
to  be  experts  in  cytology  like  the  great  masters  in  order  to 
acquire  your  degree,  but  to  acquire  accurate  general  in- 
formation on  the  subject  and  to  know  where  to  search  for 
it  and  find  the  knowledge  you  will  thirst  for  and  need  as 
you  advance  in  the  study  and  practice  of  the  great  profes- 
sion you  have  chosen. 

It  is  a  fact  that  changes  in  the  neurones  and  neurone 
groups  or  nerve  centers  precede,  accompany,  or  correspond, 
to  all  changes  in  function  of  organs  innervated  from  or 
through    them    or    through    their    influence,  whether    these 


52 

hanges  may  always  be  demonstrated  or  not.  All  alteration 
oi  function  in  cell  action  is  accompanied  with  correlative  or 
corresponding  alteration  in  structure,  either  in  change  of  form 
or  relative  position  of  cell  molecules — changes  ol  shape  or 
texture.  This  is  a  law  that  pervades  all  nature.  You  know 
in  nature  the  trembling  of  a  leaf,  the  waving  of  a  bough  and 
the  movement  of  the  wind  and  the  ripple  in  the  brook  where 
yon  batlud  and  fished,  differ  as  the  movement  of  the  different 
powers  of  the  lever,  of  the  wheel  axel  or  the  pulley.  Differ- 
ences in  shape,  structure  and  adjustment  make  the  differences 
in  motion  in  mechanics  and  physics.  It  does  the  same  in 
physiology  and  pathology.  Variations  in  quality  or  quantity  of 
plasma,  in  blood  supply,  in  form  and  texture  of  organs,  viscera, 
nerves  or  entire  nerve  cells  or  neurones,  cause  variations 
in  action,  in  disease,  contrasted  with  healthy  physiological 
and  anatomical  states.  Physiologic  or  normal  or  natural 
function  in  organ  or  neurone  is  health  and  pathology  or 
diseased  function  is  altered  physiological  structure  and  ac- 
tion— /.  <'.,  normal  function  changed  by  morbific  or  disease 
engendering  cause.  Physiology  is  anatomy  in  action,  disease 
is  pathology  in  action,  whether  in  aggregate  organ,  the 
components  of  its  cells  or  the  entire  cell,  /'.  e.,  the  nucleus, 
nucleolus,  axis  cylinder,  neuraxone  and  their  ramifications, 
all  of  which  contribute  to  make  the  neurone.  A  neurone 
diseased,  acts  abnormally  and  in  order  to  act  abnormally  it 
must  be  anatomically  diseased  in  shape  or  size  or  structure 
or  in  the  plasmic  structure  or  neuroglia  that  holds  the  neu- 
rone in  place.  The  old  axiom  of  creation,  ex  nihil  facere,  is 
a  fallacy;   something  cannot  be  made  from  nothing. 

As  this  is  true,  so  also  is  it  true  that  no  absolutely 
functional  disease  can  exist.  We  speak  of  functional  nerv- 
ous diseases  as  those  diseases  which  as  yet  have  no 
definitely  discovered  underlying    pathologic    cause,     but    we 


53 

do  not  mean  thereby  that  only  function  is  disordered  without 
actual  causative  structural  change.  In  functional  diseases  of 
the  nervous  system  so-called,  causative  conditions  undoubt- 
edly exist  in  the  dominating  neurones  beyond  the  ken  of 
science  in  all  nervous  disease  or  they  are  in  the  nourishing 
pabulum,  the  blood  or  blood  serum  supplied  them,  as  in 
anaemic  neurasthenia,  in  which  we  know  the  impoverished 
state  of  the  blood  but  not  the  precise  condition  always  of 
the  neuratrophic  cell  or  neurone  that  causes  the  character- 
istic debility  and  peculiar  symptomatic  fears.  When  the  great 
Virchow  promulgated  his  cellular  pathology  he  used  the 
term  cell,  when  referring  to  the  central  nervous  system,  in 
much  the  same  sense  as  we  now  employ  the  term  neurone. 
Though  the  neurone  theory,  the  individuality  and  independ- 
ence of  the  neurone  as  now  understood,  was  not  then  so  pre- 
cisely known  in  neuropathology  and  neurophysiology,  yet  he 
founded  the  cellular  pathology.  Under  your  microscopes  in 
the  biological  laboratory  you  will  discern  many  varieties  of 
appearance  among  glia  cells  and  neurones  and  also  in  your 
text-books  you  will  find  them  described.  The  study  is  fascina- 
ting but  I  cannot  go  over  it  all,  nor  can  you  during  the  term 
and  do  your  other  work  well.  Only  bird's-eye  views  are 
here  permitted  as  to  the  tlying  visitor,  but  take  in  all  you  can 
at  a  glance. 

These  neurone  variations  have  to  do  with  the  differences 
of  physiological  functions,  as  the  pyramidal  shaped  neurones 
or  cells  of  the  grey  cortex  of  the  brain  and  the  motor  neurones 
of  the  anterior  cornua  or  horns  of  the  spinal  cord,  and  of  the 
ganglionic  centers  of  the  sympathetic  system.  Not  only  the 
external  morphology  but  the  internal  morphology  of  the 
neurones  constitute  a  vast  field  of  research  as  up  to 
the  present  time  discovered  and  the  field  will  grow  wider 
for   your   entertainment    and    your    instruction  as  you  go  on 


54 

or  proceed  along  the  pathway  of  medical  cytology.  The 
internal  and  external  morphology  and  the  grouping  and 
chaining  together  of  the  neurones  constiute  the  burden  of 
Lewellyn  Barker's  great  labor  as  revealed  in  his  recent 
great  book  of  more  than  eleven  hundred  pages  of  plate  and 
copy,  on  the  nervous  system  in  its  cytological  aspects. 

Neurone  changes  have  been  shown  of  the  effects  of 
increased  body  heat  by  Goldschneider  and  Flotaw,  and  from 
poisoning  by  Malol  nitrit  and  tetanus  toxine,  after  section 
of  the  nerve  root  in  rabbits  by  Erlanger.  Spinal  cord 
neurone  changes  have  been  shown  by  Marinesco  and  others 
from  cutting  off  blood  supply,  and  of  the  end  of  the  spinal 
cord  in  cerebro- spinal  meningitis  by  Barker,  who  produces 
all  these  1  have  mentioned  and  many  others  in  his  splendid 
book,  and  Nissl,  Vangehuchten,  Berkley,  Robertson,  Morrison 
and  others  have  shown  the  changes  of  neurones  under 
arsenic,  alcohol,  etc. 

Intoxications  and  infections,  animal  and  mineral,  both 
from  within  and  without  the  human  structure  alter  the 
structure  and  function  of  the  neurones  and  consequently  of 
all  organs  or  parts  of  organs  dependent  upon  them  for 
speech  expression.  Alcohol  may  so  change  the  neurones  of 
the  speech  center  of  Broca  as  to  set  the  tongue  to  wagging 
or  so  as  to  paralyze  it,  or  of  the  psychic  neurones  of  the 
several  layers  of  the  grey  cortex  of  the  brain  so  as  to  increase 
mental  action  to  boistrous  insanity  or  depress  it  to  alcoholic 
coma  or  so  effect  the  psychic  or  psycho -motor  neurones  as 
to  cause  alcoholic  epilepsy,  (that  is  a  fit  of  coma  and  con- 
vulsions induced  by  the  alcoholic  poisoning  of  the  psychic 
and  psychomotor  areas  of  the  brain  with  irritation  and 
paralysis  of  the  vaso-motor  centers). 

A  proper  understanding  of  the  neurones  and  the  parts 
they    play  in  healthy  and  diseased  states  is  a  large  part  of 


the  study  of  neurology  and  psychology  and  a  knowledge  oi 
the  effect  of  medicinal  and  other  influences  upon  them  is  a 
large  part  of  the  neuriatry  or  healing  of  nervous  diseases 
and  psychiatry  or  the  treatment  of  mental  diseases. 

Regis,  who  writes  so  concisely  and  so  well  in  his  manual 
on  mental  medicine  which  1  have  before  referred  to,  has 
contributed  a  number  of  recent  monographs  and  so  have  many 
other  authors  on  auto-intoxication  and  delirium — the  psy- 
choses of  auto-intoxication — and  the  post  eclamptic  psychoses. 
Here  the  psychic  psycho -motor  neurones  are  potently  and 
morbidly  touched  as  we  see  them  changed  in  action  by  the 
intangible  and  visually  undiscemible  virus  of  a  fever,  save 
when  we  bring  microscopic  lenses  of  great  magnifying  power 
to  our  aid  postmortem.  We  may  see  evidences  of  the 
neurones  being  lightly  touched  as  in  the  delirium  of 
bilious  remittent  fever  so-called,  when  the  bacilli  of 
Laveran  invade  the  brain  cells  lightly  and  resistance  is  great 
or  they  overwhelm  resistance,  when  the  cerebral  congestion 
of  a  "congestive  chill"  sets  in,  or  in  the  still  graver  states  of 
septic  infection  or  of  typhus  and  typhoid  and  the  grave  deli- 
rium that  ends  life.  In  these  fatal  states  when  the  life  of  all 
the  blood  is  touched  corruptibly  and  "the  poor  brain  doth  by 
the  idle  comments  that  it  makes  foretell  the  ending  of 
mortality,"  the  death  dealing  microbes  and  disorganized 
blood  have  got'  in  their  fatally  destructive  work,  not  only 
upon  the  vitality  of  the  neurones  of  mental  movement 
in  the  domain  of  psychic  life  and  dethroned  mentality,  but 
in  the  vital  centers  of  organic  life  and  cut  short  vital 
metabolisms  or  essential  changes  of  existence  and  destroyed 
vital  visceral  functions.  When  the  neurones  are  embarrassed 
by  toxic  germ  or  auto-toxine,  function  fails.  When  they 
are  poisoned  till  they  cannot  functionate,  their  actions  are 
palsied  and  the  functions  and  life  they  govern  cease. 


56 

What  gets  into  the  delicate  textures  of  the  eye  con-- 
ocins  the  ophthalmologist,  the  specific  virus  of  a  gonorrhoea 
for  instance, as  it  likewise  concerns  the  gynecologist  and  the 
gonoccocus  may  migrate  far  away  from  the  urethra  even  to 
the  brain  as  well  as  to  the  joints  and  other  parts  and  be- 
come of  equal  interest  to  the  alienist  and  neurologist.  What- 
ever germ  attacks  the  neurone  concerns  the  neurologist,  whether 
it  be  the  bacillus  of  tetanus  in  the  motor  nerve  center  of 
brain  or  cord  or  the  germ  of  diphtheria  or  la  grippe,  which  may 
attack'  any  portion  of  the  cerebro-spinal  system  or  of  malaria 
which  in  my  judgment  and  observation  may  be  as  fated  as 
either.  The  study  of  germs  is  germain  to  neurology  and 
psychiatry.  They  are  causative  factors  often.  Morbid  con- 
ditions of  the  neurones  give  us  nervous  and  mental  disease 
and  morbid  processes  elsewhere  in  other  than  the  nervous 
system  give  us  diseased  neurones  to  consider.  Here  are  a 
few  microscopic  examples.  But  there  are  hundreds  more  to  be 
found  in  the  domain  of  illustrated  morbid  cytology.  But  we 
cannot  take  your  time  now  to  show  them. 

FIG.   26. 

/lfert//?AZ/5A'£UfilOff£S,  B/&BASED 


— Commencing 
atrophy  of  a  cell  from 
the  anterior  horn  of  the 
spinal  cord.  Degenera- 
tion of  the  nucleus. 
Magn.  150.  OWs&^er 

Intra  and  extra  neural  disease  explained  in  subsequent  chapters 


-Simple  atrophy 
of  a  iierve-cellfrom  the 
oculomotor  nucleus. 
Human.     Magn.  150. 


—Fatty-pigmentary 
degeneration  of  a  pyra- 
midal cell  of  the  cortex 
cerebri.     Magn.  150. 


FIG.   27. 


-H% 


■«• 


*^<^.  5W«e  metope*  *«Ws>  o^  ocr^btCkX  ooxCex  o^  a-  &o$j 
f-Oae  Vw^WilaW'^oC^1'^  s\u^l^VcaxiwsA,jy»  Corpora- 


FIG.  28. 


VvN.  g&h 


Fig.  28  represents  the  cell  of  anterior  horn  of  the  spinal  cord  of  a 
normal  rabbit,  while  Fig.  29  is  the  cell  of  the  anterior  horn  of  the  spinal 
cord  of  a  rabbit  with  experimental  elevation  of  temperature.  Both  are  after 
Ford  Robertson. 


FIG.   30. 


u 


w* 


*4Hr 


x^fttaX  xxexve  sWw'om^  xevuMxxxa  ctaxoxtvo&oW- 

emo.  ox  ^N&\,Vx\g  <5^  >&&  xx^vvcoxxe  CVkqw  OwpcN- 
Uw,\V\\R0t6i\M*   \U©€  US.     AFTER  /l/lAR.iNE%lo-KAY- 

cJoxViaexcucfc,  CX,«vcoBm\Q^,3%xxv^xGX\x7ce^re.xV^cv- 


FIG.   31. 


o^v^o    * 


JLss  >  vuw 


FIG.    J2. 


— From  the  cornu  Ammonis  of  the  rabbit.  A,  Composite  figure  from 
preparations  by  S.  R.  y  Cajal.  n,  b,  c,  Association-cells  whose  long  neuraxons 
split  up  into  moss-like  twigs,  which  invade  the  layer  of  pyramidal  cells  (A). 
At  the  left  is  a  completely-sketched  pyramidal  cell.  Through  its  descending 
neuraxon  it  is  in  relation  with  the  "brain-pith"  and  through  its  ascending  den- 
drites it  is  in  relation  with  other  systems  and  cells  not  figured.  Through  the  asso- 
•ciation-eells  many  pyramidal  cells  are  brought  into  combination. 

HOW   CORTEX   NEURONES   COMMUNICATE  AND   PROJECT. 
FIG.  33. 


Scheme  nhowinc  thu  pri.hnhlc  course  <>f  impulses  and  the  interneu- 
toual  connections  in  the  cortex  cerebri.  (After  8.  Ramon  y  Cajal  Lea 
nouvellea  i.l.Vs.  etc,-.  Axnulay,  Pari-,  1894,  p.  flfi,  Fig.  16.)  ,1.  srtMlr  pvniin- 
uial  cell;  II,  large  pyramidal  <  .11  .  (\  l>.  polymorphous  cells;  /.'.  terminal 
centripetal  projection  fibre  ;  /•'.  collaterals  fnnu  the  gulistantia  alba  ;  (f,  axuue 
bifurcating  in  the  substantia  alba. 


3  " 


if  ,pwi 


Scheme  of   the  fibres  propria-  connected  with  the  commissural  system  of 
the  brain  convolutions. 


BERKLEY'S   DIAGRAM   OF  THE  PROJECTION   FIBER  SYSTEM 
OF  THE   BRAIN. 

FIG.   36. 


Showing  the  origin  and  course  of  the  pyramidal  and  callosal  fibers. 
P,  pyramidal  tract:  C,  callosal  commissure;  A,  cell  sending  an  axone 
directly  to  the  collateral  hemisphere;  B,  H,  cells  having  branched  axones; 
the  main  fibers  descend  into  the  pyramidal  ways,  and  the  collaterals  cross 
to  the  opposite  half  of  the  brain  through  the  corpus  callosum;  1,  I,  cells 
sending  fibers  directly  into  the  pyramidal  tracts  without  branching. 


FIG.   38. 


FIG.  37. 


FIG.   39. 


FIG.   40. 


FIG.  41. 


MEYNERT'S   SCHEME   OF   THE   COMMISSI   RA1     FIBER   SYSTI  M. 


FIG.  42. 


For  further  description  see  Chapter  V 


CHAPTER  VI. 

THE    NEURONES    GROUPED   INTO    LAYERS   OR     STRATA     OF     THE     BRAIN 

CORTEX;      FURTHER    CONSIDERATION    OF  THE   NEURONES  AND  OF 

THE  ASSOCIATION    FIBER  SYSTEM  OF    THE   BRAIN   AND  OF  THE 

PROJECTION  SYSTEM  OF  THE   BRAIN  AND  SPINAL  CORD. 

FUNCTIONS  OF  NEUROGLIA  AND  MESOGLIA. 


The  neurones  of  the  cortex  are  often  distributed  over 
six  or  more  layers,  laminations  or  strata.  This  cut  of  Mey- 
nert  (Fig.  34)  shovys  the  five  motor  strata  with  their  neu- 
rones as  usually  described.     The  sensory  areas  have  more. 

The  first  zone  or  stratum  is  made  up  of  polymorphous 
neurones  of  what  are  commonly  called  cells  of  the  Golgi  type. 

The  second  layer  is  composed  of  small  pyramidal  neu- 
rones with  intermediate  connecting  glia  or  Dieter's  cells. 

The  third  layer  is  composed  of  medium  sized  and  larger 
pyramidal  neurones. 

The  fourth  of  compacted  small  pyramidal  cells. 

The  fifth  of  medium,  large,  and  giant  pyramidal  neu- 
rones, and  the  sixth  is  made  up  of  medium-sized  polymor- 
phous neurones,  mingled  with  the  substratum  layer  of  white 
substance  described  only  as  white  substance  by  Meynert 
as  you  may  see  by  reference  to  the  illustration,  from  that 
distinguished  neuro-anatomist,  to  be  seen  in  Fig.  34  of 
this  volume.  Meynert's  illustration  which  I  show  you  gives 
the  neurones  in  th^  motor  area  of  the  anterior  lobes;  the 
five  strata  layers. 

[57] 


58 

The  six  or  more  stratifications  or  layers  of  the  brain  do 
not  belong  to  the  motor  area  but  to  the  "annectant  gyri" 
which  connect  the  occipital  and  parietal  lobes.  These  six 
or  more  layers  belong  to  what  has  been  called  the  sensory 
type  of  neurone  layers  of  the  brain. 

The  first  layer,  beginning  in  the  cortex,  just  beneath  the 
meninges,  contains  the  so-called  tangential  fibers.  Where  a 
sixth  layer  is  recognized  it  is  constituted  of  medullary  sub- 
stance containing  a  few  spindle-shaped  neurones.  The  neu- 
rones of  the  first  layer  are  irregularly  angular  with  angular 
nuclei,  those  of  the  second  are  small  pyramidal.  The  third 
are  larger  pyramids  in  shape. 

There  are  many  varieties  of  neuroglia  besides  those  of 
the  Golgi  type  which  I  have  shown  and  Ford  Robertson's 
mesoglia,  like  unto  them. 

Fig.  37  shows  an  ependymal  cell  from  the  pituitary  body 
approximating  the  embryonic  type;  Fig.  38,  ependymal  cells 
of  fir-tree  form  from  the  margin  of  the  third  ventricle  adja- 
cent to  the  infundibulum ;  Fig.  39,  long-rayed  neuroglia  cell 
from  the  fourth  layer  of  the  cortex,  a  transition  form  between 
the  ordinary  long-rayed  and  mossy  form;  Fig.  40,  neuroglia 
cells  of  horse-tail  form  from  the  peridyme  of  the  brain.  The 
free  surface  is  covered  with  a  felt-work  of  the  longitudinal 
fibres;  Fig.  41,  a  mossy  cell  with  knobbed  branches  from 
the  gray  matter  of  the  cortex.     All  are  from  Berkley. 

Figs.  37,  38,  39,  are  from  the  adult  dog,  the  others  are 
from  man.  Berkley  has  transcribed  into  his  masterly  work 
on  mental  diseases  sixteen  varieties,  some  of  which  1  show 
you  as  tending  to  confirm  the  conviction  he  expresses  that  in 
addition  to  Binswhanger's  view  of  their  gliacyte  or  cell  con- 
necting function  already  referred  to,  they  serve  the  double 
function  of  support  and  separation  of  cells,  neuraxones  and 
dendrites   besides    being  "factors  in  the    lymph  circulation" 


59 

which  has  been   hinted   at  in  our  reference  to  the  irrigation 
system  of  the  brain,  the  perivascular  spaces,  etc. 
"In  human  movements  though  labored  on  with  pain 

A  thousand  movements  scarce  one  purpose  gain, 

In  God's,  one  single  can  its  end  produce 

And  yet  serve  to  second  some  other  use." 

And  so  it  is,  probably,  with  the  relationship  of  the 
neuroglia  to  the  neurone. 

And  so  doubtless  you  will  conclude  from  an  examina- 
tion of  these  varied  illustrations,  a  few  of  which  1  reproduce 
for  your  consideration  and  perhaps  some  of  you  may  make 
the  necessary  investigations  to  settle  the  question  here  pro- 
pounded, do  the  neuroglia  nourish  as  well  as  mechanically 
support  the  neurones?  Fame  lies  in  the  paths  that  may 
lead  you  to  a  correct,  unerring  answer  to  this  important 
question.  Remember  as  you  study  this  subject  what  1  have 
told  you  of  invariable  variations  of  structure  corresponding 
to  deviations  in  function  and  note  how  differently  in  appear- 
ance and  construction  is  the  ependymal  neuroglia  cell  from  the 
pituitary  with  that  fir-tree  form  of  the  third  ventricle  neu- 
roglia and  that  of  the  fourth  layer  of  the  cortex  and  compare 
these  with  the  mossy  glia  cell  No.  10  of  the  second  layer  for 
the  neurones  and  that,  besides  mechanical  support  which  is 
demonstrable,  the  neuroglia  may  give  the  neurones  physio- 
logical support  in  the  way  of  lymph  nutrition,  this  latter, 
however,  being  yet  only  conjectural  and  I  will  pass  you  on 
this  answer  or  if  you  but  say  the  neuroglia  act  the  part  of 
a  physiological  scaffolding  glue  to  the  neurones.  Apropos 
to  your  future  investigations,  read  Bevan  Lewis'  discussion 
of  the  lymphatic  system  of  the  brain  and  especially  before 
and  after  the  paragraphs  I  here  quote.* 

*Beyond  the  system  of  perivascular  channels,  adventitial  lymph  space,  and  perivascu- 
lar sac,  we  have  a  lymph-connective  system  which  plays  an  important  role  in  the  pathology 
of  the  brain.  This  system  is  constituted  by  the  larger  connective  element.  These  elements, 
more  closely  examined,  are  found  to  have  a  definite  and  constant  relationship  to  the  cortical 
blood  vessels;  and  are  always  discovered  in  large  numbers  in  their  immediate  neighborhood, 
external  to  the  perivascular  channels. — Bevan  Lewis,  page  83. 


60 

Are  the  neuroglia  connected  with  the  nutrient  lymph 
system  of  the  brain?  1  think  they  are.  Golgi,  Clouston, 
Robertson,  Berkley  and  others  think  so,  :\nJ  Ramon  y  Cajal 
says:  "They  expand  and  contract  the  capillaries  to  which 
they  are  attached."     Study  up  this  subject. 

W.  Bevan  Lewis,!  considering  that  recent  research  into 
the  general  morphology  and  intimate  histological  structure 
of  the  nerve  cell  has  so  far  enlarged  the  boundaries  of  our 
knowledge  that  it  becomes  essential  to  start  with  a  definite 
terminology  which  includes  no  ambiguous  terms  for  the 
complicated  apparatus  presented  as  the  modern  conception 
of  a  nerve  cell,  would  thus  describe  the  neurone  and  its 
several  components. 

The  body  of  the  cell  including  all  its  contents,  he  calls 
the  cell  or  neurocyte;  the  protoplasmic  body  of  the  cell,  in 
contra-distinction  to  the  nucleus,  he  proposes  to  term  the 
neurosome  or  cytoplasm.  If  the  cell  is  provided  with  pro- 
toplasmic processes  he  would  speak  ot  the  main  trunk  as 
the  dendrone,  and  the  finer  arborizations  as  the  dendrites.  If 
one  of  these  occupy  a  polar  position  whilst  the  others  rise 
from  the  base  or  sides,  as  in  the  pyramidal  cells  of  the 
cortex,  he  would  designate  the  former  as  apical  or  primary 
dendrons,  and  the  others  as  lateral,  basal  or  secondary 
dendrons.  The  dendrone,  remember,  is  not  an  essential  part 
of  the  cell,  since  many  nerve  cells  have  no  dendrone.  The 
axis  cylinder,  he  thinks,  may  be  much  more  conveniently 
termed  the  axone,  which  may  be  naked  (non-medullated)  or 
medullated,  and  such  branches  as  arise  along  its  course  as 
collaterals.  The  distal  termination  of  an  axone  or  its  col- 
laterals in  a  plexus  he  designates  as  terminal  arborization 
and  for  the  whole  system  thus  embraced,  i.  e.,  the  neuro- 
cyte with    its  axone  (collaterals,  terminal  arborizations,  and 

tText-bonk  Mental  Diseases,  2d  edition,  pace  60. 


61 

if  present,  the  dendritic  expansions),  we  use  preferably  the 
term  neurone  in  the  original  sense  adopted    by  Waldeyer.'" 

I  show  you  these  great  things  from  the  great  masters 
to  set  you  to  thinking;  not  that  I  expect  to  make  you  at 
once  great  cytologists  like  these  masters  are;  nor  that  1 
expect  you  to  remember  minutely  all  1  tell  you. 

Tell  me  at  the  final  examination  that  the  neuroglia, 
though  varied  in  form,  are  connecting  tissue  supports  to 
keep  the  neurones  in  place  and  maybe  to  help  feed  them, 
and  your  answer  will  be  satisfactory.  It  will  even  be  sat- 
isfactory if  you  only  know  and  say  the  neuroglia  are  the 
framework  of  the  neurones,  for  this  is  all  we  now  seem 
absolutely  to  know.  But  you  may  conjecture  other  func- 
tions for  these  intermediate  structures  between,  some  of 
them  looking  like  spiders,  others  like  whips  or  horses'  tails, 
others  like  the  branches  and  stems  of  trees,  and  to  prove 
new  functions  for  the  neuroglia  if  you  can  and  I  expect  to 
hear  from  you  affirmatively  in  the  on-coming  days  of  your 
higher  neurological  climbing.  Men  climb  in  science  as  boys 
climb  trees,  from  trunk  to  limb  and  from  limb  to  smaller 
branch  till  they  reach  the  possible  top. 

From  what  I  have  thus  far  said  it  must  have  already 
appeared  to  you,  that  to  know  the  neurones  well  is  to 
know  neurology.  You  have  seen  that  a  neurone  is  a  min- 
iature nervous  system.  It  has  in  its  nuclei  its  central  system 
and  in  its  neuraxone  and  dendrites  its  peripheral  connective 
system,  afferent  and  efferent,  and  neuroglial  relations,  its 
association  and  projection  fibers,  as  I  have  said.  Aggregate 
these  single  neurones  and  neuroglia  and  you  make  the  brain, 
made  up  of  the  prosencephalon  or  fore-brain,  the  thalamen- 
cephalon  or  inter-brain,  the  mid-brain  or  mesencephalon 
and  the  hind  and  after-brains  embracing  the  pons,  cerebel- 

*Deutsche  Medicinalischc  Wochenschrift ,  1891. 


62 

lum  and  medulla.  The  grouping  and  "chaining  together  of 
the  neurones"  or  their  normal  integrity,  anatomically  held 
together  by  means  of  their  neurone  and  neurite  prolongations 
and  neuroglia,  make  the  projection  paths  and  association 
paths  and  make  possible  the  physiology  of  the  entire  nervous 
system,  the  entire  cerebro-spinal  axis  and  peripheral  systems. 

The  severing  of  a  single  neurone  link  in  this  neurotic 
chain  or  the  damaging  of  the  neuroglia  which  hold  the  links 
of  the  nervous  chain  in  normal  place, makes  neuropathology. 
It  may  be  very  slight,  so  slight  that  we  cannot  detect  the 
anatomical  change,  as  in  the  so-called  neuroses,  as  formerly 
more  generally  understood,  or  functional  nervous  diseases. 
They  were  originally  so  called  as  they  are  now  because 
the  anatomical  change  into  pathological  change  causing  them 
is  not  yet  definitely  detectable.  But  neuroses  are  nervous 
diseases  with  pathological  bases  like  other  diseases-;  the 
symptoms  and  organ  affected  being  known,  but  their  precise 
pathology  awaiting  further  discovery. 

Now  then,  linked  together  so  beautifully  in  exact  ana- 
tomical relations,  we  have  the  neurones  that  make  up  the 
great  cerebro-spinal  system  of  cerebrum,  cerebellum,  pons 
Varolii,  basal  ganglia,  crura,  medulla,  cord  and  sensory  and 
motor  nerve  connections.  And  the  association  and  projection 
systems  and  neuroglia  referred  to,  hold  all  in  that  normal 
healthy  anatomical  relation  that  makes  the  physiology  of 
the  cerebro-spinal  system  appear  so  beautifully  and  won- 
drously  accurate  and  simple  with  all  of  its  complexity.  Break 
the  connection  anywhere  and  you  have  neuraxis  or  nerve 
center  disease  and  thus  recurs  again  the  poetic  aphorism, 

"From  Nature's  chain  whatever  link  you  strike, 
Tenth  or  ten  thousandth,  breaks  the  chain  alike," 

and  you  may  have  disease  as  grave  as  cerebro-spinal  scle- 
rosis with  its  intention  tremor  or  cerebral  apoplexy  with  its 


63 

coma  and  paralysis,  or  neuroses  so  slight  as  the  passing 
tremor  or  evanescent  paresis  of  stage  fright. 

When  the  people,  your  future  patients,  come  to  under- 
stand this,  as  they  will,  with  the  diffusion  of  medical  like 
other  scientific  truth  among  them,  they  will  not  wait  till 
the  brain  breaks  under  the  burden  of  business  or  grief  or 
passion's  excess  or  other  mistakes  of  living  and  bad  nervous 
system  care  and  management,  before  consulting  you.  They 
will  seek  medical  counsel  in  time  to  avoid  catastrophe  to 
the  delicately  wrought,  yet  wonderfully  strong  nervous 
system,  considering  the  abusive  strains  to  which  it  is  sub- 
jected and  which  it  endures  before  it  gives  way  to  the 
pressure  of  adverse  environment,  in  our  modern  strenuous 
life. 

The  erroneous  popular  teaching  that  the  mind,  because 
immaterial,  is  independent  of  the  body,  and  that  will  power, 
which  is  nothing  less  nor  more  than  good  or  ill  endowed 
psychic-neurone  power,  can  do  everything  or  almost  every- 
thing, is  responsible  for  the  ignoring  of  the  neurologist,  the 
neglect  of  timely  attention  to  the  needs  of  the  nervous 
system  and  the  gradual  or  sudden  and  fatal  brain  break- 
downs and  needlessly  early  deaths  among  so  many  of  our 
men  of  affairs,  at  the  very  time  when  they  are  most  needed 
and  ought  to  do  their  best  brain  work. 

It  will  be  your  business  to  impress  the  danger  of  the 
reckless  prodigal  overstrain  of  psychic  neurones  and  the 
importance  of  timely  care  of  them  on  the  people  who 
employ  you  for  wise  and  prudent  counsel  pertaining  to  their 
health.  Man  is  a  bundle  of  neurones  and  those  people 
who  speak  of  themselves  as  bundles  of  nerves,  because 
they  are  so  irritable,  easily  frightened,  perturbed,  sleepless 
or  otherwise  nervous,  are  bundles  of  unstable  neurones 
which  need  neurological  attention.     They  need  their  psychic 


64 

neurones  looked  after  as  much  as  the  implements  of  their 
business  need  repairing  from  time  to  time.  They  need  to 
be  sent  to  pasture  from  time  to  time  like  their  tired  horses, 
or  to  the  shop  for  repairs  like  their  wagons  or  harness. 
Teach  your  patients  to  be  sensibly  good  to  themselves  and 
kindly  and  timely  considerate  of  their  neurones  and  they  will 
be  good  to  you,  by  employing  your  aid  more,  and  kind  to 
themselves,  by  giving  you  a  chance  for  timely  attention 
to  themselves,  when  you  may  save  them  from  those  grave 
neuropathic  calamities  that  now  needlessly  befall  so  many 
good  men  in  all  lines  of  strenuous  action. 

The  brain  is  made  an  anatomical  and  a  physiological 
whole,  and  the  spinal  cord  likewise,  by  the  association  and 
projection  communicating  systems  of  the  brain  and  cord.  You 
see  you  are  to  have  great  use  for  this  knowledge,  for  disease 
damages  or  dissevers  these  normal  relations.  When  it  only 
disturbs  or  damages  relations  you  have  less  serious  lesions 
to  deal  with  than  when  disease  destroys  relations.  Tremors, 
tremulousness,  feebleness,,  perverted  movements  come  from 
disturbances  of  neuraxial  relations  short  of  destruction. 

Destruction  makes  even  perverted  function  impossible 
and  then  you  have  paralysis.  The  destroyed  motor  centre 
makes  motion  impossible.  The  motor  center  touched  by  disease 
short  of  destruction  that  is  irritated,  gives  spasm  or  contrac- 
tion, or  alternating  contraction  and  relaxation,  which  is  convul- 
sion or  tremor,  because  there  remain  undestroyed  neurones  to 
be  disordered  in  action  and  intact  projection  tracts  to  convey 
disordered  action  outward  from  the  centers  of  spine  or  cord.  If 
the  projection  tracts  are  impaired  you  have  impaired  or  altered 
action,  but  still  action;  if  destroyed  you  have  no  action  or 
paralysis;  if  partly  destroyed  you  have  partial  paralysis  or 
paresis.  Refer  in  the  study  of  this  interesting  projection  fiber 
system  to  Figs.   14,  24,  33  and  compare  with   13  and  22. 


65 

We  have  already  seen  and  shall  presently  see  more 
from  other  illustrations  as  well  as  this  one,  how  the  projec- 
tion fibers  converge  from  the  cortex  to  form  the  corpora 
striata  and  pass  downward  and  outward  in  the  crura  and 
cord  tracts.  Some  of  these  fibers  are  fine  and  some  are 
coarse,  some  longer  and  some  shorter.  The  projection  fibers 
belong  mainly  to  the  neuraxis,  connecting  brain  with  spinal 
cord  centers.  The  association  fibers  described  in  the  fol- 
lowing and  preceding  illustrations  belong  to  the  brain. 

Ford  Robertson  has  called  attention  to  the  fact  which 
he  has  brought  out  by  the  platinum  method  of  staining  that 
"the  structures  described  as  neuroglia  do  not  consist  of  one 
tissue,  as  has  been  generally  believed,  but  are  composed  of 
at  least  two  kinds  of  cell  elements  of  which  the  origin, 
morphology,  functions  and  behavior  in  morbid  conditions  are 
entirely  distinct."  The  advanced  student  may  be  interested 
in  the  above  note  and  Robertson's  plates  xviii,  xix  and  xx, 
but  you  will  not  be  examined  on  this  subdivision  of  the 
neuroglia  in  the  final  examinations.  Andreisen,  whom  he 
quotes,  has  described  the  neuroglia  as  made  up  of  separate 
epiblastic  and  mesoblastic  elements  but  somewhat  different 
from  those  observed  by  W.  Ford  Robertson,  who  suggests 
that  the  neuroglia  containing  epiblastic  elements  should 
only  be  called  neuroglia  and  those  containing  mesoblastic 
elements  should  be  termed  mesoglia  cells,  illustration  of 
which  you  may  see  by  reference  to  Robertson's  plate  xx. 
But  though  Robertson  makes  a  beautiful  demonstration  of 
his  contention  by  his  platinum  method,  as  the  illustrations 
establish,  we  shall  call  them  all  neuroglia.  They  are  both 
engaged  in  similar  business,  these  mesoglia  and  neuroglia 
or  blastoglia  and  mesoglia,  if  you  choose,  viz.:  that  of 
sustaining  the  neurones  at  their  respective  stations  and 
posts    of     duty.       Different     parts     of     the     neuroglia     do, 


66 

however,  seem  to  behave  differently  under  disease  but  as 
they  'belong  to  some  nerve  tenter  and  are  manifest  with  its 
disease  1  will  not  discuss  either  mesoglial  or  blastoglial 
diseases,  as  1  would  term  disease  of  the  remainder  of  the 
neuroglia  for  purposes  of  distinction. 

We  cannot  dwell  longer  among  the  neurones  and  neu- 
roglia. My  vocation  as  educator  is  to  lead  you  into  the 
ways  of  Knowledge  necessary  for  your  advancement  in  the 
essentials  of  neurology.  It  is  your  duty  to  go  on  farther  in 
these  pathways  or  in  new  ones  which  you  may  mark  out 
for  yourselves. 

After  you  shall  have  become  advanced  students  of  cytol- 
ogy you  may  have  the  inclination  to  take  up  this  subject 
and  pursue  it  in  extenso.  We  cannot  go  further  now.  Ford 
Robertson  concedes  that  his  mesoglia  are  about  as  numer- 
ous as  the  neuroglia  and  they  are  certainly  so  closely  mixed 
up  and  interlaced  with  them  that  we  consider  them  together. 
So  when  I  talk  about  neuroglia  or  quiz  you  upon  the  sub- 
ject 1  shall  mean  to  include  all  under  the  one  term  neuroglia 
for  the  present.  Robertson  aptly  calls  them  "the  guy 
ropes  for  the  capillaries"  as  well  as  the  supports  of  the 
nerve  cells  and  prolongations,  and  you  may  see  the  neu- 
roglia often  attached  to  the  capillaries.  He  says  they  are 
repair  tissues,  for  the  brain  is  like  tissues  in  other  parts  of 
the  body  and  this  is  in  harmony  with  Bevan  Lewis'  suste- 
nance idea.  Here  our  study  of  the  nutrient  network  of  the 
neurones  must  close  for  the  present.  The  further  illustra- 
tions which  follow  must  suffice  as  objective  lessons  in  lieu 
of  another  lecture  on  the  subject. 

The  neuraxones  or  axis-cylinder  processes  of  neurones 
are  either  long  or  short,  terminating  close  to  their  parent 
neurones  or  far  from  them.  The  latter  are  typified  in  the 
pyramidal    neurones    or    projection    cells   of    Shaeffer,   which 


(>7 

send  their  neuraxones  down  into  the  cord  or  across  the  hrain, 
through  the  corpus  callosum.  They  are  chiefly  motor  im- 
pulse cells.  The  shorter  neurones  are  called  intermediary 
cells  and  are  connecting  neurones  to  other  neurones.  They 
are  a  type  of  Golgi  cells,  so  called  because  described  by 
this  great  investigator  in  cytology.  He  thought  they  were 
exclusively  sensory  cells,  a  view  not  generally  entertained 
now,  but  1  am  not  sure  this  view  ought  to  have  been 
abandoned.  The  shape  of  the  brain  cortex  neurones,  besides 
being  designated  as  pyramidal,  apolar,  bi-polar,  multi-polar, 
etc.,  are  also  called  stellate,  ovoid,  etc.,  but  Meynert's 
division  into  pyramidal,  mixed  granule  form  and  spindle- 
shaped  about  covers  the  varieties  in  conformation. 

The  fibrae  propriae,  connecting  neighboring  convolutions 
of  the  cortex,  and  the  longer  commissural  fibers  which  connect 
more  distant  cortex  areas  with  each  other,  appear  somewhat 
as  in  illustrations  Figs.  22  and  35.  They  and  other  fibers 
make  possible  the  traversing  of  a  cortex  irritation,  like  that 
of  an  epilepsia,  for  instance,  from  one  point,  the  point  of 
the  initial  aura,  for  example,  to  others  distant  in  the  brain. 
But  they  do  not  appear  quite  so  plain  under  the  microscope 
as  in  these  diagrams.  Artifacts,  that  is,  artificial  or  after- 
death  products  resulting  from  handling  of  the  brain,  tissue, 
rupture,  etc.,  post-mortem  appear,  under  the  lense,  to  in- 
terrupt and  otherwise  obscure  the  appearances  of  these 
important  fibers.  This  accounts  for  the  diagrams  of  different 
microscopists  varying  a  little.  But  in  the  main  their  out- 
lines are  in  accord,  those  of  that  excellent  one  by  one  of 
the  latest  observers,  Vangehuchten,  with  the  comparatively 
small  number  traced  and  named  by  Edinger,  whose  classical 
and  standard  diagram  is  to  be  found  in  many  of  your  text- 
books, and  which  shows  the  following  tracts.  It  will  be 
easy  for  you  to   become    familiar  with  all    the    other  details 


68 

in    neurocytology.     But    you    are    glad,   no    doubt,  that    the 
number  is  so  limited. 

These  tracts  are  the  uncinate  or  hook-shaped  fibers 
going  from  the  cortex  of  the  temporal  lobe  forward  along 
the  ventral  border  of  the  insula  into  the  ventral  regions 
of  the  frontal  lobe;  the  arcuate  fibers,  or  fasculi  arcuati, 
which  pass  over  the  dorsal  part  of  the  insula  from  the  most 
posterior  portion  of  the  temporal  lobe  to  the  cortex  of  the 
parietal  and  frontal  lobes.  Next  the  cingulum,  a  long  tract 
that  runs  in  the  marginal  gyrus  —  gyrus  fornicatus  —  from 
the  cortex  of  the  cornu  ammonis  to  the  most  ventral 
region  of  the  frontal  lobe,  including  the  olfactory  lobe  in 
the  dog,  rabbit,  etc.  Then  we  have  the  inferior  longitudinal 
fibers  running  antero-posteriorly  across  the  brain  and  con- 
necting temporal  with  occipital  lobes  and  the  fronto-occipital 
fibers  of  the  fasculus  fronto-occipitalis,  as  Edinger  describes 
them,  "arising  from  the  medullary  covering  of  the  posterior 
and  lateral  horns  of  the  ventricle,  its  fibers  passing  forward 
as  a  well-defined  bundle  external  to  the  lateral  ventricle," 
beneath  the  corpus  callosum  and  on  the  dorsal  edge  of  the 
nucleus  caudatus.  The  arcuate  fibers  and  the  fibers  of  the 
cingulum  belting  the  corpus  callosum  are  all  antero- posterior 
fibers.  Almost  all  of  the  inter-lateral  or  crossed  commissural 
fibers  pass  transversely  through  the  corpus  callosum  or 
anterior  commissure  or  crossing,  and  are  called  in  the  litera- 
ture, transverse  callosal  or  transverse  commissural  fibers  or 
fasciculi.  There  are  other  lesser  fibers  called  forceps  major, 
forceps  minor  and  the  tapetum  corporis  callosi  or  the  band 
or  tape  shape  bundle  of  fibers  which  pass  in  either  hemi- 
sphere through  the  corpus  callosum  to  the  temporal  lobe. 
The  fibers  of  the  forceps  major  come  from  the  occipital 
lobe,  run  in  the  corpus  callosum  and  surround  the  posterior 
horn  of    the    lateral   ventricle    like  a  cap,   resembling    some- 


69 

what  the  fibra?  propria?.  "That  portion  of  the  corpus  callo- 
sum  passing  into  the  temporal  lobe  on  the  lateral  side  of 
the  inferior  horn  of  the  lateral  ventricle  is  called  the  forceps 
minor." 

These  terms  are  used  for  the  purpose  of  minute  de- 
scription by  brain  histologists.  You  do  not  need  to  carry 
them  all  continuously  in  your  minds,  but  only  to  know 
where  to  find  them  when  referring  to  the  plates  of  the 
text-books  in  studying  minute  brain  descriptions.  Remem- 
ber, however,  the  general  direction  and  arrangement  of  the 
connection  and  projection  fibers  of  the  brain.  And  their 
courses  go  crosswise,  lengthwise,  obliquely  and  downward 
in  the  brain,  through  and  over  the  corpus  callosum,  about 
and  over  the  ventricles,  to  and  through  the  basal  ganglia, 
the  longer  tracts  going  down  the  cord.  They  are  inter- 
cerebral,  circumgyral,  corticle,  spinal,  etc.,  as  their  courses 
studied  in  a  case  of  apoplexia,  post-mortem  for  instance, 
with  Marchi  osmium  stain  will  often  show  you,  especially 
in  the  tracing  of  the  downward  or  descending  degenerations 
of  this  cerebral  disease. 

I  can  not  here  enter  more  minutely  into  this  branch  of 
a  most  interesting  subject.  But  I  commend  to  you  for 
vacation  reading,  in  connection  with  this  and  preceding 
lectures,  Meynert,  translated  by  B.  Sachs,  of  New  York, 
on  the  Anatomy,  Physiology  and  Nutrition  of  the  Brain; 
Obersteiner,  Edinger,  Robertson,  Morrison,  Lewis  and  others 
already  mentioned. 

The  tumor  most  peculiar  to  the  neurologlial  network 
bears  the  name  of  this  structure  and  is  called  glioma.  The 
neuroglia  of  the  brain  and  pons  is  the  most  frequent  seat 
of  this  form  of  brain  tumor. 

Inflammation  and  gummata  are  most  common  in  the 
meninges  and  arteries. 


NEUROGLIA  CHANGES   IN   CEREBRAL   DISEASE. 
(After  Ford  Robertson.) 

FIG.  43. 


•  • :  •  •  .;. 

00    *  *  ,  • 


w     ....  %-    ft  ■••■•• 


S  , 


Vi*».V»        • 


Description  of  fig.  43. 

Fig.  11.  Outermost  layer  of  normal  cerebral  cortex  (human)  (x300). 
The  dark,  rounded  nuclei  are  mostly  those  of  neuroglia  cells. 

Fig.  12.  Outermost  layer  of  cerebral  cortex  from  a  case  of  advanced 
general  paralysis,  showing  great  hypertrophy  of  neuroglia,  and  thickening 
of  the  vessel  walls.     (x300.) 

Fig.  13.  Outermost  layer  of  cerebral  cortex  from  a  case  of  senile  in- 
sanity, showing  a  moderate  degree  of  hypertrophy  and  hyperplasia  of  the 
neuroglia,  sub-pial  felting  (containing  some  colloid  bodies),  and  thickening 
of  vessels.     The  neuroglia  cells  are  pigmented.     (x300.) 

Fig.  14.  Outermost  layer  of  cerebral  cortex  from  a  case  of  epileptic 
insanity,  showing  slight  hypertrophy  of  neuroglia,  together  with  marked 
sub-pial  felting.     (x300.) 

Fig.  15.  Two  greatly  hypertrophied  neuroglia  cells  from  the  tissues 
adjoining  a  small  secondary  carcinomatous  nodule  in  the  cerebrum.  Analine 
black,  fresh  method.  (x500.)  Tumors,  localized  centers  of  inflammation, 
and  recent  softenings  are  generally  surrounded  by  a  broad  zone  of  neuroglia 
cells  of  this  kind.  They  are  swollen  to  several  times  their  normal  size, 
and  it  can  be  recognized  that  many  of  them  are  divided.  Note  the  dendritic 
branching  of  the  processes. 

Fig.  16.  Greatly  hypertrophied  neuroglia  cells,  surrounding  an  arte- 
riole in  the  deepest  layer  of  the  cortex,  in  a  case  of  advanced  general 
paralysis.  Analine  black,  fresh  method.  (x500.)  The  arteriole  shows 
periarteritis.     The  nerve  cells  have  for  the  most  part  disappeared. 

FIG.  44. 


Neuroglia  Cells  of  the  Brais,  their  Relations  to  the 
Blood- Vessels  ;  also  the  Sustentacolar  Processes  of  the  Epithelial  Cells  of  the 
Litftiai.  Ventricle  Otarchi).  A,  Epithelial  cells  lining  lateral  TeDtricle;  a,  process  of 
S£.mt,  6,  upiiier  or  nenoglia  cell;  c,  blood-vessel. 


CHAPTER  VII. 

HEAD   HEAT   IN   BRAIN   DISEASE,   CEREBRAL     THERMOMETRY,   AND 
CEPHALIC    GALVANIZATION  — THEIR    VALUE    IN 
DIAGNOSIS  AND   PRACTICE. 


Temperature  taking  since  Wunderlich  and  Liebermeister 
has  become  in  medicine  a  routine  proceeding  and  the  clin- 
ical thermometer  is  almost  as  familiar  as  the  tongue  and 
pulse  in  practice.  From  sublingual  axillary  and  rectal  tem- 
perature taking  and  the  testing  of  the  palmar  heat  by  Couty, 
the  practice  has  passed  in  clinical  neurology  through  the 
studies  of  Broca,  Alvarengo,  Maragliano,  Sepelli,  Albers, 
Gray,  Amidon,  Mills,  Lombard  and  others  to  the  head. 

In  that  great  Italian  asylum  for  the  insane  at  Reggio 
Amelia  where  chiefly  brain  diseases  in  their  extreme  and 
most  calamitous  degree  come  under  notice,  the  two  distin- 
guished Italian  neurologists  and  alienists  of  Reggio  Amelia 
made  painstaking  studies  of  cerebral  thermometry  in  paresis 
or  general  paralysis  of  the  insane,  melancholia,  furious 
mania,  etc.  These  studies  will  interest  you,  for  these  cases 
will  often  come  under  your  notice  as  well  as  all  degrees 
below  them  of  mental  impairment,  down  to  the  morbid  psy- 
chic caprices  and  hallucinations  of  hysteria  and  the  morbid 
fears  of  mysophobia  and  neurasthenia. 

Paolo  Bert  found  by  self-experimentation  when  the 
temperature  of  the  brain  was  not  equal  on  both  sides,  it 
was  higher  over  the    left  hemisphere  in  the  frontal    region. 

[70] 


71 

The  heat  was  also  highest  on  the  left  during  intellectual 
activity.  Others  have  confirmed  this  observation.  Mills 
found  augmented  temperature  in  a  tumor  of  the  right  frontal 
lobe  which  was  found  on  autopsy  to  have  destroyed  the 
anterior  half  of  the  first  and  second  convolutions,  part  of 
the  corpus  callosum  and  gyrus  fornicatus,  but  it  did  not 
involve  the  speech  center  of  Broca,  hence  though  halluci- 
nated, mentally  enfeebled,  and  with  headache,  vomiting  and 
having  nystagmus,  impaired  vision,  olfaction  and  general 
sensation  with  dilated  and  fixed  pupils,  his  speech  power 
was  intact.  He  had  no  aphasia.  This  is  important  for  you 
to  note  with  reference  to  a  discussion  of  speech  center 
disease  or  aphasia  later  in  this  course. 

My  lamented  friend,  Landon  Carter  Gray,  early  put  on 
record  a  lesion  which  he  claims  was  the  first  intracranial 
tumor  diagnosticated  by  cerebral  thermometry.  It  was  a 
glioma.  The  clinical  symptoms  pointed  to  the  base  but  he 
located  the  tumor  at  the  lateral  aspect  of  the  cerebrum  and 
the  autopsy  confirmed  the  thermometric  diagnosis. 

The  average  temperature  of  the  right  side  of  the  head, 
the  side  of  the  tumor,  was  QQ0^';  of  the  left  side  it  was 
ge0!^,  and  of  the  whole  head  97°84/.  Since  then  Mills 
has  reported  one  case  of  frontal  tumor  and  a  gumma  of  the 
corpus  callosum  diagnosticated  in  part  by  local  head  heat 
increase;  Eskridge,  a  tumor  of  the  cerebellum  with  monocu- 
lar hemianopsia,  and  Putnam  Jacobi  a  tubercular  meningitis 
in  the  same  way. 

Maragliano  proved  the  thermometers  could  indicate 
accurately  the  temperature  of  the  skull  by  filling  the  latter 
with  water  at  different  temperatures  and  testing  thermomet- 
rically  the  temperature  through  the  scalp  and  hair  which  he 
did  not  remove  from  the  cranium.  The  temperature  of  the 
water  in  the  skull  and  the  heat  on  the  scalp  surface    were 


72 

shown  by  simultaneous    water  and    surface   heat    measure- 
ment-* to  correspond. 

But  do  not  be  misled  into  concluding  th.it,  with  no  cranial 
increase  of  temperature  existing,  there  can  be  no  cranial 
disease.  I  have  had  one  or  two  such  cases  myself.  A 
brain  tumor  may  exceptionally  develop  so  slowlv  as  to  not 
excite  heat  developing  irritation  for  a  time. 

Maragliano,  Sepelli  and  Broca  selected  points  behind  the 
external  orbital  epiphysis  for  the  frontal  region;  above  the 
insertion  of  the  ear  for  the  temporal  region;  and  along  side 
the  median  line  for  the  occipital  region.  The  six  centigrade 
thermometers  used  by  them  "for  better  isolation,  were  cov- 
ered with  a  little  carded  cotton  wool  and  were  fixed  by 
means  of  a  circular  bandage,  special  care  being  taken  that 
the  bulbs  were  not  pressed  against  the  surface  of  the  cra- 
nium. In  the  women  the  hairs  were  accurately  divided,  so 
that  the  elongated  bulb  of  the  thermometer  might  come 
into  close  contact  with  the  scalp.  The  duration  of  the 
application  was  half  an  hour  for  each  patient.  Application 
was  made  in  the  axilla  and  the  rectum  in  immediate  suc- 
cession to  those  on  the  head,  with  the  view  of  avoiding 
any  false  interpretation  of  the  latter;  *  *  febrile  states  may 
sometimes  interpose,  in  patients  examined,  and  the  aug- 
mented temperature  of  the  cranium  then  noted,  might  be 
attributed  to  local  influence,  whilst,  on  the  contrary,  it  was 
but  a  manifestation  of  the  system." 

The  authors  introduce  three  tables  which  we  refrain 
from  reproducing,  substituting  this  summary,  as  the  temper- 
ature of  the  normal  brain  as  measured  through  the  cranium 
is  from  3>£  to  4)4  degrees  less  than  it  is  in  the  axilla  or 
rectum.  "The  mean  temperature  of  the  head  in  these 
examinations  reached  its  maximum  in  furious  mania  {mania 
confurore),  36.89;   and  in  a  progressively  decreasing  line,  in 


73 

lypemania  agitata,  36.81;  in  general  paresis  (paralisi  progres- 
siva), 36.63;  in  dementia  agitata,  36.45;  in  imbecility  and 
idiocy,  36.34;  in  mania,  without  fury,  36.30;  in  simple  lype- 
mania, 36.17;  and  finally,  in  tranquil  dementia,  36.03,  cen- 
tigrade markings."  The  easiest  way  of  turning  these  into 
Fahrenheit  is  to  multiply  by  2;  deduct  one-tenth  the  product 
and  then  add  32°.  Thus  36.89x2=73.78-1-10  =  66.40, 
plus    32°=  98.40. 

There  were  differences  between  Maragliano's,  Gray's, 
Broca's  and  Sepelli's  results  due  somewhat  to  the  different 
season  at  which  their  respective  observations  were  made  in 
June,  July  and  August;  Broca's  and  Gray's  being  in  colder 
weather,  Sepelli  and  Maragliano  remind  us  (see  Alienist 
and  Neurologist  as  previously  quoted)  that  "Wunderlich 
alluding  to  the  various  precautions  to  be  taken  in  thermo- 
metric  practice,  observes  that  in  observations  made  in  sum- 
mer, it  may  be  useful  to  take  account  of  the  surrounding 
temperature  and  that  if  such  an  observance  is  of  value  in 
axillary  and  rectal  thermometry,  it  must  be  still  more  so  in 
relation  to  that  on  the  head." 

SEPELLI'S    CEREBRAL    THERMOMETRY    MEASUREMENTS. 

1st.  The  medium  temperature  of  the  sane  man  is, 
according  to  Sepelli's  thermometric  measurements,  "36.13  for 
the  left  side  and  36.08  for  the  right— 36.10  for  the  whole 
head.  As  to  the  diverse  regions  the  means  of  the  frontal 
lobes  are  36.20  for  the  left  and  36.15  for  the  right;  of  the 
parietal,  36.18  for  the  left  and  36.15  for  the  right;  of  the 
occipital,  36.13  for  the  left  and  36.08  for  the    right." 

2d.  "In  the  insane,  except  in  simple  lypemania  and 
dementia,  the  mean  temperature  of  the  head  is  above  normal, 
the  highest  degree  being  reached  by  mania  with  fury 
(36.89);  lypemania    next    (36.81),    then    general    paralysis 


74 

i.63) ;  dementia    agitata  (36.45);  imbecility    and    idiotism 

(^6.54);    mania     without     fury    (36.30);     simple     dementia 
(36.03). 

3d.  "In  all  the  forms  of  mental  disease  the  occipital 
lobes,  as  in  the  sane  man,  give  a  temperature  lower  than 
the  other  lobes;  the  temperature  of  the  frontal  lobes,  which 
equals  that  of  the  parietal  in  dementia  agitata,  imbecility 
and  idiotism,  excels  it  in  mania,  simple  lypemania  and 
simple  dementia,  whilst  in  general  paralysis  and  lypemania 
agitata  the  temperature  of  the  parietal  lobes  "is  higher  than 
that  of  the  frontal. 

4th.  In  all  the  principal  groups  of  mental  diseases, the 
mean  of  the  two  halves  of  the  head  is  almost  equal,  except 
in  congenital  forms.  Here  the  right  half  presents  figures 
higher  than  those  of  the  left. 

(This  tends  to  substantiate  Wigan's  idea  that  it  is 
when  the  entire  brain  is  involved  and  the  balancing  and 
correcting  influence  of  the  opposite  hemisphere  is  impaired 
by  disease  that  insanity  appears.  —  Hughes.) 

5th.  The  results  of  cerebral  thermometry,  placed  in 
accord  with  what  is  known  of  the  pathological  anatomy  of 
insanity,  confirm  the  fact  that  in  general  paralysis,  mania 
and  divers  periods  of  exaltation,  which  are  frequently  man- 
ifested even  in  forms  of  depression  and  mental  enfeeblement, 
there  exists 'a  state  of  hyperemia  of  the  brain. 

6th.  The  surrounding  temperature  has  a  notable  influ- 
ence on  the  results  of  cerebral  thermometry. 

7th.  The  general  temperature  of  the  body  in  the  insane, 
taken  in  the  axilla  or  in  the  rectum,  is  greater  in  lypemania 
agitata  and  mania  furiosa,  and  in  decreasing  order  it  pro- 
ceeds, diminishing  in  general  paralysis,  dementia  agitata, 
mania  without  fury,  imbecility  and  idiocy,  tranquil  dementia 
and  simple  lypemania." 


75 

These  results  were  obtained  at  the  insane  asylum  o1 
Reggio  Emilia  Sept.  20,  1878.  They  have  not  been  inval- 
idated by  later  observations  and  have  served  me  well  in 
the  clinical  study  of  brain  disease  as  they  will  serve  you. 

Professor  E.  Maragliano  read  to  the  medical  congress  at 
Pisa  September  26,  1879,  the  result  of  a  series  of  experi- 
ments made  by  him  in  his  School  of  General  Pathology,  in 
Genoa.  He  first,  by  means  of  experimental  investigations* 
sought  to  eliminate  whatever  doubt  might  arise  as  regards 
the  capacity  of  the  cranial  walls  to  transmit  promptly  in 
thermometers  placed  on  the  exterior,  the  internal  oscillations 
of  temperature.  With  this  view  he  applied  thermometers  to 
the  exterior  of  different  cranial  envelopments,  which  were 
filled  with  water,  at  various  temperatures,  and  he  was  able 
to  see  that  the  thermometers  on  the  outside  rapidly  followed 
the  oscillations  shown  by  those  placed  inside. 

He  next  studied  the  physiological  and  pathological  tem- 
perature, and  that  present  during  chloralic  sleep.  The 
conclusions  which  he  drew  from  these  researches  were  the 
following: 

1st.  The  thermometers  applied  to  the  cranial  integu- 
ments faithfully  follow  the  thermal  internal  oscillations. 

2d.  The  cerebral  temperature  revealed  in  this  manner 
in  physiological  conditions  is  shown  more  elevated  on  the 
left  than  on  the  right  side,  especially  by  thermometers 
placed  near  the  frontal  region.  (The  left  is  the  driving  side 
of  the  brain,  or,  preferably,  active  side  ordinarily. — H.) 

3d.  The  degree  of  temperature  varies  according  to  age 
and  sex. 

4th.  In  the  same  individual  there  are  presented  in  the 
course  of  a  day,  from  time  to  time,  elevations  or  depressions 
which  do  not  exceed  half   a  degree. 

5th.  The  cerebral    temperature    may    have  relations  to 


76 

pathology,  but  relatively  to  the  conditions  existing  between 
the  two  sides,  or  between  points  on  the  same  side. 

6th.  To  have  absolute  value,  elevations  or  depressions, 
at  least  one  degree  above  the  physiological  mean,  arc 
called  for. 

7th.  In  cerebral  embolism  there  is  a  diminution  in  the 
lobe  irrigated  by  the  plugged  vessel,  from  which  may  be 
deduced  an  important  diagnostic  criterion. 

8th.  During  the  chloral  sleep  there  is  a  constant  dimi- 
nution of  the  cerebral  temperature.  (Suggesting  arteriole 
contraction. — H.) 

Thus  you  see  the  importance  and  utility  of  cerebral 
thermometry  in  brain  disease  has  been  placed  beyond  doubt 
by  Maragliano,  SepelLi,  Broca,  Clouston,  Gray,  Mills,  Voisin 
and  many  others.  It  is  an  element  of  diagnosis  as  Voisin 
claimed  "matching  in  value  that  of  the  stethoscope  in  dis- 
eases of   the  chest." 

In  Voisin's  experiments  on  healthy  brains  the  maximum 
figure  for  the  cranium  never  exceeded  36°  (96.8  F.)  even 
when  the  brain  was  in  a  state  of  functional  activity,  and 
with  diminution  of  this,  the  cerebral  temperature  descended 
concurrently  to  a  lower  figure.  Voisin,  Maragliano  and  Sepelli 
proved  cranial  hyperemia  in  general  paralysis  and  in  all  of 
the  cases  of  insanity  with  maniacal  delirium,  also  in  hyper- 
emia by  cranial  thermometry. 

The  case  described  by  Gray  of  cerebral  thermometry, 
already  referred  to,  was  that  of  a  woman  aged  34,  in  which 
a  pupillary  stasis,  paroxysms  of  pain  in  the  temporal  and 
superciliary  regions,  nausea,  vomiting,  ptosis  and  paralysis 
of  the  ocular  muscles,  had  led  the  physician  to  form  the 
diagnosis  of  intercranial  tumors,  situate  at  the  base  of  the 
brain;    Gray  having  the  opportunity  of  observing  it  applied 


77 

the  thermometer  on  various  parts  of   the  head  and  obtained 
the  following  results: 

LEFT.  RIGHT. 

Frontal    region 95°  75  98"  33 

Parietal       "     95  99    75 

Occipital     "     96    75         100    60 

Resting  on  these  data,  he  was  able  to  conclude  that 
the  lesion  must  be  extended  from  the  base  of  the  Sylvian 
fissure  backwards  along  the  right  occipital  lobe.  The 
autopsy  showed  the  existence  of  a  gliomatuous  tumor,  situ- 
ate between  the  horizontal  or  posterior  branch  of  the  Sylvian 
fissure,  and  the  parallel  one  of  the  right  side,  whilst  the 
entire  occipital  lobe  was  converted  into  a  colloid  mass, 
extremely  vascular.  The  meninges  were  unaltered.  (The 
above  and  the  following  are  taken  from  Maragliano  and 
Sepelli's  paper  in  Revista  Spermentali  and  translated  into  the 
Alienist  and  Neurologist,  vol.  I,  nos.   1  and  2.)* 

The  other  case,  communicated  to  the  Philadelphia  Path- 
ological Society  by  Dr.  Mills,  on  November  14th,  was  that 
of  a  man  aged  36,  in  which  the  principal  symptoms  were 
intense  headache,  vomiting,  mental  enfeeblement,  hallucina- 
tions, but  without  delirium,  no  disturbance  of  the  speech, 
slight  paralysis  of  the  left  arm,  weakness  in  the  lower 
limbs,  deviation  of  the  head  to  the  right,  nystagmus,  blunted 
sensibility,  diminution  of  vision  and  of  olfaction,  dilated 
pupils  and  pupillary  stasis.  The  cerebral  temperature  taken 
for  seven  days  preceding  death,  gave  as  mean,  the  follow- 
ing figures: 

Frontal  median    region 35.83 

Frontal  left  "     34.83 

Parietal    "  " 34.66 

Occipital  median  35.27 

Frontal  right  "     35.00 

Parietal     "  "     :.34.83 

*The  translation  of  the  cases  of  Mills  and  Gray  into  the  medical  literature  of  Italv 
show  a  flattering:  appreciation  of  American  experimental  clinical  work,  for  which  the  author 
cordially  thanks  his  eminent  Italian  confreres  in  neurology. 


7S 

Bert  followed  up  these  by  exploring  cranial  tempera- 
ture areas  corresponding  to  localities  of  brain,  regarded  as 
the  seats  of  diverse  functions  and  found  some  exaltations 
of  temperature  to  follow  intense  psychomotor  activity,  but  I 
have  not  the  precise  focal  results  to  give  you  of  his  subse- 
quent experiments.  1  think  the  range,  however,  did  not 
exceed    one    degree. 

Since  all  tissue  are  heat  producers  or  thermogenic  dur- 
ing vital  activity,  the  brain  is  no  exception,  notwithstand- 
ing its  special  thermogenic  centers.  The  liver  is  probably 
the  greatest  heat  producer,  the  blood  from  its  haepatic  vein 
being  warmer  than  that  of  the  portal  vein  going  to  it,  and 
muscles  in  action  are  thermogenic. 

"The  normal  axillary  temperature  is  about  37.5  C,  that 
of  the  mouth  a  little  higher  and  of  the  rectum  slightly  more 
elevated.  The  mean  temperature  of  the  blood  is  placed  at 
39  C."     (Wesley  Mills.) 

The  mean  temperature  of  the  body  accessible  to  the 
thermometer  varies  not  more  than  a  degree  and  a  half 
centigrade.  The  temperature  of  the  haepatic  vein  (Wesley 
Mills  Physiology)  has  been  put  down  at  39.7  C,  and  it 
contains,  as  already  said,  the  warmest  blood  of  the  body. 
The  average  normal  temperature  of  the  head  through  the 
cranium  is  36.10. 

THE   EFFECTS  OF  CEPHALIC   ELECTRIZATION   ON 
HEAD  HEAT  AND  HEAD  CONGESTION. 

It  is  more  than  thirty  years  since  I  began  the  practice 
of  cephalic  galvanization  for  epilepsy,  cerebral  hyperemia, 
hyperaemic  headaches,  cerebral  hypothermia  and  other  con- 
ditions associated  with  vaso-motor  instability  and  arteriole 
irregularity  in  the  brain's  circulation  apparatus.  In  support 
of  the  views  1  long  ago  held  on"  this  subject  1  published  in 


7<) 

the  Alienist  and  Neurologist  for  January,  1880,  M.  Ch. 
Letournian's  experimental  contribution  undertaken  to  deter- 
mine what  is  the  effect  upon  the  vessels  of  the  brain,  of  a 
moderate  electrization  with  the  galvanic  (continuous)  cur- 
rent through  integuments  and  the  cranial  wall  as  nearly  as 
practicable  in  conforming  to  ordinary  therapeutic  applica- 
tions. He  made  bare  in  a  mammiferous  animal  a  portion 
of  the  cerebral  membranes  and  proceeded  with  the  follow- 
ing demonstrations,  securing  a  most  valuable  and  triumphant 
demonstration  of  the  inestimable  physiologico-therapeutic 
fact  that  galvanism  of  the  meninges  of  the  brain  will  con- 
tract the  arterioles  of  the  brain's  enveloping  membranes, 
and  I  can  likewise  assure  you  the  same  agency  so  applied 
from  os  frontes  to  nuchae,  with  thoroughly  wet  sponge 
electrodes,  P.  pole  to  neck,  N.  pole  so  as  to  reach  the 
cerebral  vaso- motor  centers  of  other  parts  of  the  brain  by 
the  current's  course,  will  favorably  impress  brain  congestion 
and  arteriole  irregularity  and  help  in  the  cure  of  curable 
cases  of  epilepsy,  etc.,  of  which  1  shall  speak  in  detail  later. 
"Doctor  Laborde  assisted  him  in  the  experiment  on  a 
kitten  a  month  old,  in  which  the  cranial  wall  was  still  very 
thin  and  was  quite  easy  to  cut,  a  considerable  portion  of 
cranium  had  been  cut  on  the  left  side.  The  dura  mater 
being  so  exposed  it  was  very  easy  to  see  with  the  naked 
eye,  and  still  better  with  a  magnifying  glass,  the  arterial 
and  venous  branches  which  ramify  upon  the  surface.  They 
proceeded  then  to  the  electrization,  making  use  of  the  small 
portable  pile  for  continuous  current,  of  MM.  Onimus  and 
Brown.  This  pile  contains  eighteen  elements  and  they  took 
care  by  the  aid  of  a  galvanometer  introduced  into  the  cir- 
cuit to  assure  themselves  that  the  passage  of  the  current 
was  effected  regularly.  During  all  the  duration  of  the 
experiment,  the    positive    pole    was    placed  behind  the  right 


80 

.  cending  ramus  of  the  inferior  maxilla  and  the  negative 
pole  upon  the  anterior  cranial  region  above  the  eyes. 

Ten  or  fifteen  seconds  after  the  closing  of  the  circuit, 
the  fine  arterial  branchings  of  the  dura  mater  became  less 
and  less  visible,  and  a  little  later,  the  venous  branches  them- 
selves became  pale.  At  each  interruption  of  the  current 
the  anemia  increased  for  an  instant,  then  the  vessels 
resumed,  little  by  little,  a  little  larger  caliber. 

The  experiment,  repeated  a  number  of  times,  gave 
always  the  same  results,  determined  successively  by  Doc- 
tors Duval,  Laborde,  Conderceau  and  themselves.  The 
dura  mater  of  the  right  side  having  been  denuded  in  its 
turn,  the  experiment  was  repeated,  which  on  this  side 
again  gave  the  same  results.  They  pursued  the  experi- 
ment, cutting  on  the  left  side  a  portion  of  the  dura  mater. 
The  pia  mater  being  thus  exposed,  and  its  vascular 
branches,  arterial  and  venous,  being  very  visible  upon  the 
gray  ground  of  the  cerebral  substance,  the  same  observa- 
tions were  made  upon  it.  There  also,  we  could  obtain  at 
will,  contraction  of  the  vessels. 

The  experiments  just  related,  they  go  on  to  state,  added  to 
facts  cited  in  the  commencement  of  this  paper,  put  it  beyond 
doubt  thai  it  is  possible,  even  easy,  to  produce  in  man  a  tem- 
porary anemia  of  the  brain,  by  means  of  suitable  electrisation; 
but  the  therapeutical  bearing  of  this  fact  should  not  escape  the 
physician.  For  litis  temporary  anemia  can,  without  the  least 
inconvenience,  be  renewed  a  great  number  of  times  daily,  if  one 
wishes;  and  ow  personal  experience  permits  us  to  affirm  that, 
with  a  little  persistence  one  may  triumph  so  over  various  con- 
gestive states  of  the  brain,  manifesting  themselves  either  by  the 
simple  depression  of  the  intellectual  faculties  or  by  psychical 
disorders  of  varied  nature. 

In  support  of  the  preceding  statement  they  cite  a  typ- 


81 

ical  case  of  chronic  congestion  of  the  brain,  which  has 
yielded  to  electrization  repeated  persistently,  but  which 
we  omit. 

The  abbe  C,  aged  fifty-five  years,  is  a  corpulent,  full- 
blooded  person,  with  a  highly  colored  countenance;  he 
applied  to  us  in  despair  because  he  suffered  several  times 
a  week  from  persistent  vertigo,  during  the  duration  of 
which  he  could  not  take  a  step  without  support,  and  from 
which  he  was  relieved  only  by  absolute  repose.  M.  C. 
belonged  to  a  religious  community  whose  principal  object 
is  teaching,  but  he  was  obliged  to  renounce,  little  by  little, 
all  work.  It  had  come  to  pass,  he  said,  that  he  could 
scarcely  recite  his  breviary  and  say  mass.  After  various 
treatment,  there  was  made  to  him,  at  the  end  of  five 
months,  an  application  of  fifteen  leeches,  with  so  little  effect 
that  the  next  day  he  had  a  severe  cerebral  congestion, with 
loss  of  consciousness  and  instantaneous  fall.  This  serious 
accident  occurred  several  times  afterwards,  and  was  ordinar- 
ily accompanied  by  violent  vomiting. 

To  modify  this  inveterate  organic  state  and  restore  a 
proper  tonic  contraction  to  vessels  habitually  dilated,  a 
treatment  of  long  duration  was  necessary.  During  five 
months  they  electrized  the  patient  three  times  a  week, 
placing  the  positive  pole  of  a  pile  with  continuous  current 
at  the  level  of  the  first  cervical  vertebra,  the  negative  pole 
at  the  level  of  the  superior  ganglion  of  one  of  the  cervical 
sympathetic  nerves.  The  number  of  elements  employed 
varied  from  fifteen  to  twenty,  and  they  took  care  to  inter- 
rupt the  current  every  fifteen  seconds;  for  experience  shows 
that  vascular  contraction  is  produced  especially  at  the  open- 
ing and  closing  of  the  current. 

Each  seance  effected  an  immediate  amelioration  and 
longer    and    longer.     Soon  the    patient  was  able    to  resume 


82 

his  occupation,  and  to  work,  at  first,  one  hour,  then  two 
hours,  then  four  and  five  hours  per  day.  At  the  same  time 
the  attacks  of  vertigo  became  more  and  more  rare  and  brief. 
At  the  end  of  five  months,  the  patient  ceased  a  treatment 
which  was  no  longer  necessary;  and  for  several  months  the 
alleviation  has  continued.* 

This  fact  is  so  eloquent,  they  say,  that  it  appears  to  them 
useless  to  accompany  it  with  comments,  and  it  will  surely 
suggest  to  practicing  physicians,  therapeutic  applications 
numerous  and  various." 


*GazctU  Hebdom.,  3  Oct.,  1879. 


CHAPTER  VIII. 

THE    TEMPERATURE  SENSE,  ETC.,  AND    ITS   ALTERATIONS    IN    DIAGNOSIS. 
THE   MUSCULAR  SENSE  AND  SENSE  OF  WEIGHT. 


The  condition  of  the  temperature  sense  is  best  deter- 
mined, after  ascertaining  the  real  thermal  condition  of  the 
patient  by  means  of  the  ordinary  clinical  thermometer,  by 
applying  to  the  patient's  skin  alternately  hot  and  cold  and 
warm  waterdiscs  or  bottles  or  sponges  of  water,  hot,  cold 
and  warm,  and  interrogating  him  as  to  what  degree  of  heat 
sensation  he  feels  at  each  application. 

If  you  have  reason  to  suspect  the  patient  or  wish  to 
exclude  the  possibility  of  malingering,  apply  the  temperature 
tests  unexpectedly  and  out  of  the  range  of  the  patient's 
vision  at  the  time.  He  should  also  be  otherwise  managed 
about  as  in  making  an  ordinary  asstheseometric 
examination  with  an  asstheseometer,  i.  e.,  suggestion  of 
what  tests  you  are  about  to  use  should  be  avoided.  He 
should  neither  see  the  water  heated  nor  cooled,  boiled 
nor   frozen. 

Besides  BecquerePs  discsand  Lombard's  thermo- electrical 
differential  calorimeter  they  use  in  some  of  the  Paris  hospitals 
an  instrument  called  Blocq's  thermoassthesiometer,  but  an 
ordinary  bath  or  water  thermometer  perforating  a  rubber 
stopper  or  disc  of  aluminum  to  keep  it  stationary  and 
upright,  and  immersed  in  a  test  tube  or  bottle  partly  filled 
with    water,  capped    to    prevent  the  water  spilling    out  and 

[83] 


84 

heated  or  cooled  to  suit  the  purpose  of  your  examination 
will  answei  quite  well.  1  show  you  the  different  devices 
and  you  may  make  your  own  choice.  I  think  mine,  like 
my  Texas  friend  Beall's  green  straw  catheter,  is  more 
readily  devised  for  the  emergency  of  country  practice  and 
less  expensive,  besides  teaching  a  lesson  in  self-reliance  in 
practice. 

Beall  used  to  make  capital  fly  blisters  of  potato  bugs, 
mashed  and  rolled  with  lard  and  a  rolling  pin,  and  they  draw 
well.  If  you  should  be  called  to  a  patient  with  high  brain 
heat,  too  much  blood  in  the  head,  a  slow,  full  pulse,  stupor 
and  delirium  or  other  apoplectic  threatenings,  put  a  sinapism 
or  fly  blister  to  the  back  of  the  neck  to  impress  the  vaso- 
motors and  through  them  contract  the  cerebral  arterioles. 
If  neither  mustard  nor  cantharides,  or  Spanish  cantharadin 
ointment  are  at  hand  and  the  potato  bugs  are  on  the  vine 
gather  them  in  and  imitate  Beall's  example.  He  made  his 
mark  on  the  profession  as  a  successful  man  of  expedients 
in  practice  like  Tom  Flornouy,  one  of  Joe  McDowell's 
patients  on  whom  McDowell  first  tried  Samuel  Thompson's 
number  six  for  dysenteric  inflammation  on  the  Hahnemann - 
ian  principle  of  similia  similibus  curantur,  sending  his 
patient  out  the  window  and  down  the  streets  of  Chillicothe 
without  his  trousers,  clasping  his  nates  with  both  hands  and 
crying  fire!  Flornouy  put  out  the  fire  in  his  rectal  rear  on  the 
more  rational  principle  of  plenty  of  cold  water  and  contraria 
contrariis  curantur  morbi. 

There  are  principles  of  practice  on  which  I  would 
always  have  you  mens  conscia  recti,  which  liberally  and 
latitudinously  translated  means,  always  be  right  on  the 
management  of  the  rectum,  liver  and  other  organs,  if  you 
would  make  a  success  in  neurological  practice.  Do  not 
treat  but  one  spot  and  that  spot  the  nervous  system    only. 


85 

And  this  reminds  me  of  an  apropos  clinical  illustration, 
vi%:  a  profound  melancholia  may  be  brought  on;  (that  is, 
where  a  previous  psychopathic  constitutional  proclivity 
exists  which  in  neurological  parlance  we  call  a  neuropathic 
diathesis,)  through  aggravated  drain  and  irritation  of  the 
neuraxis  centers,  by  a  blind  fistula  in  ano  and  cured  by  its 
prompt  and  efficient  surgical  relief.  Such  a  case  impressed 
me  early  in  my  professional  career  when  I  was  a  young 
military  hospital  surgeon.  Examining  the  patient  as  1,  even 
that  early,  was  accustomed  to  do,  all  over,  1  found  the 
fistula  and  with  my  bistuary  made  an  open  sore  of  it  and 
healed  it  from  the  bottom.  Simultaneously  with  his  rectal 
recovery,  the  rest  and  recuperation  of  his  nerve  centers 
came  about  clear  up  the  cerebro-spinal  axis  to  his  cerebrum 
and  lo !  the  melancholia  was  gone.  And  thus  it  is  in  prac- 
tice we  sometimes  make  both  ends  meet  our  purpose.  In 
such  a  case  as  this  the  proctologists  are  not  to  be  despised. 
They  are  useful  workers  at  the  other  end  of  the  neurolog- 
ical line  and  sometimes  they  may  triumphantly  exclaim, 
speaking  of  their  special  work,  finis  coronat  opus!  For 
man  is  a  "vast  chain  of  being,"  as  I  have  said,  when  we 
consider  the  intimate  relations  of  the  grouping  and  chaining 
together  of  the  wonderful  neurones  and  neurone  projection 
system  that  make  up  so  much  of  his  wondrous  organism. 

BAROMETERNATUR  OR  BAROMETER  NATURE. 

Let  me  now  call  your  attention  to  a  nervous  condition 
especially  peculiar  to  some  neurotics  in  which  a  not  easily 
describable  heaviness  of  feeling  and  malaise  possesses  the 
patient  under  low  pressure  barometric  states.  It  is  not 
Katienjammer  but  Birometematur,  as  our  German  friends 
would  say.  It  is  an  indescribable  feeling  appearing  with 
atmospheric  changes.     The  uric  acid  and  the  gouty    neuro- 


86 

path  often  show  it  in  connection  with  slight  joint  tinges 
and  muscular  pains  and  chronic  malarial  toxhaemics  who  have 
lonjj,  ago  ceased  to  have  periodic  malarial  attacks,  and 
chronic  neurasthenics  show  it.  Study  this  and  see  what 
you  can  make  of  it  in  after  years  of  your  medical  obser- 
vations. 

An  irreverent  patient  will  come  into  your  office  and 
say,  "this  weather  makes  me  feel  like  h — I;"  another  will 
more  gently  say,  "1  feel  mighty  badly  when  these  changes 
come,"  and  yet  neither  can  tell  why.  They  expect  you  to 
know  and  tell  them  why.  You  will  say  learnedly,  it  is 
barometric  or  Barometernatur  impression  and  their  peculiar 
nervous  susceptibility,  AlP°«,  meaning  pressure,  you  know, 
and  fitrpov,  measure.  You  give  them  an  insulated  seance  in  the 
static  chair,  letting  them  smell  the  generated  ozone  of  the 
battery  and  give  such  other  prescription  as  tongue,  pulse, 
etc.,  may  indicate,  say  encouragingly, it  will  help  them  and  tell 
them  to  come  again  if  they  do  not  feel  lighter  and  better 
in  a  day  or  two.  A  good  static  treatment  and  a  laxative 
relieve  this  feeling  often.  But  it  is  wise  to  see  the 
patient  more  than  once,  especially  after  the  weather  shall 
have  changed  and  if  such  a  feeling  persists  then  examine 
him  thoroughly  by  physical  blood  test  and  urinary  explora- 
tion. He  may  have  the  beginnings  of  graver  nervous 
trouble.  It  is  well  to  examine  all  patients  thoroughly  even 
when  they  complain  of  comparatively  slight  and  indefinite 
nervous  symptoms,  bearing  in  mind  the  sartorial  motto,  "a 
stitch  in  time  saves  nine,"  which  Hippocrates  might  have 
made  into  a  good  medical  aphorism  but  I  do  not  recall  that 
he  did— though  there  is  a  similar  one  in  the  saying  that 
"an  ounce  of  prevention  is  worth  a  pound  of  cure."  And 
my  friend  Marcy  says,  "an  ounce  of  taffy  is  worth  a  pound 
of  epitaphy." 


87 

When  persons  born  and  acclimated  to  our  atmosphere 
show  this  Barometernahir  their  condition  should  be  inquired 
into.  They  may  need  neurological  or  other  medical  at- 
tention. It  is  well,  in  all  such  cases,  to  establish  the 
habit  among  your  clientele  of  seeking  from  expert  sources 
to  know  the  significance  of  minor  and  incipient  ailments 
that  may  be  beyond  their  sight.  The  physician  nowadays 
may  see  things  by  revelation  of  slide  and  lens,  not  visible 
to  ordinary  observation,  as  the  astronomer  sees  the  heavens. 
There  are  things  beneath  the  over-arching  dome  of  man's 
brain,  down  among  the  neurones  of  the  cortex,  basal  ganglia, 
motor  and  sensory  tracts,  as  difficult  to  see  by  common 
sight,  as  some  distant  planets  and  stars  of  lesser  magnitude 
are  to  discern  by  other  than  expert  astronomical  vision. 

THE   MUSCULAR  SENSE  AND  SENSE  OF  WEIGHT. 

The  exact  consciousness  of  a  man's  muscular  power  is 
different  in  different  individuals.  If  you  know  that  a  man 
has  been  accurate  in  the  estimating  of  weights,  you  may 
gain  some  knowledge  of  his  deterioration  in  this  regard  if 
any  exists,  by  testing  him  with  different  weights.  Also  after 
ascertaining  if  he  is  right  or  left  handed  or  ambidextrous 
and  comparing  both  his  weight  holding  and  his  weight 
estimating  capacity.  Through  the  muscular  sense  which  is 
really  a  nerve  ending  sense  the  mind  is  informed  as  to  the 
state  of  the  muscular  tonus,  power  and  capacity  of  endur- 
ance. Some  men  are  better  endowed  in  this  particular  than 
women  and  at  some  times  than  at  others  in  their  lives. 
Elasticity  of  step,  vigor  of  muscular  movement,  erect  or 
stooping  posture  and  steadiness  of  gait  and  standing  are 
connected  with  it,  even  when  there  is  neither  muscula'r 
atrophy,  pseudo-hypertrophy  nor  sclerosis.  Absence  of 
muscular    tonus,  accurate    consciousness  of    exact    muscular 


88 

strength  and  power  associated  with  the  neurotrophia  and  the 
myatrophia  and  myasthenia  of  neurasthenia  and  are  to  be 
estimated  in  diagnosis.  The  healthy  man  has  an  approxi- 
mative normal  conception  of  his  muscular  power,  a  sense  of 
muscular  tonus  that  the  neurasthenic,  for  instance,  has  not. 
The  neurasthenic  is  uncertain  in  this  regard,  as  he  is  timid 
and  irresolute  mentally.  He  feels  constantly  tired  when  in 
mental  and  muscular  repose  and  may  tell  yuu  he  was  born 
tired.  At  any  rate,  he  has  that  constant  "tired  feeling"  the 
advertising  newspaper  quacks  are  always  on  the  lookout 
for,  and  which  means  nerve  tone  exhaustion,  but  which  the 
quacks  usually  tell  him  mean  much  more. 

A  healthy  man  has  a  normal  conception  of  where  his 
muscles  are  and  the  different  parts  of  his  body  and  can 
find  and  touch  these  parts  in  the  dark  or  blindfolded.  He 
knows  where  his  feet,  toes,  hands,  fingers,  nose,  mouth, 
ears,  etc.,  are  and  can  touch  them  readily  with  his  eyes 
shut.  Flex  one  of  his  limbs  and  he  can  tell  you  without 
the  use  of  his  eyes,  what  you  have  done.  When  the 
muscular  sense  is  defective  this  can  either  not  be  known  to 
the  person  or  it  is  imperfectly  appreciated  according  to  the 
degree  of  impairment. 

In  locomotor  ataxia  for  instance  this  defect  is  so  grave 
that  the  ground  does  not  feel  natural  to  the  victim  of  this 
disease  when  walking  and  he  cannot  find  his  nose  tip, 
approximate  his  finger  tips  or  touch  his  ear  lobes  with  accu- 
racy when  his  eyes  are  shut.  This  is  a  blending  of  impaired 
muscular  sense  and  incoordination.  The  sensory  nervous 
system  is  impaired  in  locomotor  ataxia  and  the  nervous  mech- 
anism of  the  muscular  system  misinforms  the  brain  when 
the  muscular  sense,  as  it  has  been  termed,  is    impaired. 

The  tactile  sense  or  the  general  sensation  sense,  is 
different    from  the    muscular    sense,  for   they  may  be  inde- 


89 


pendently  impaired.  It  resides  chiefly  in  the  finger  tips  or 
on  the  skin  and  is  important  in  diagnosis,  as  we  shall  dis- 
cover later.  The  tactile  sense  is  the  sense  of  touch  and  is 
measured  by  touching.  The  chief  instruments  for  it  are 
the  assthesiometer  and  the  thermosesthesiometer,  the  former 
already  shown  you  and  the  latter,  thermoa_jsthesiometer,  1 
show  you  now. 

The  muscular  sense  is  not  tested  by  the  dynamometer 
which  1  now  show  you  but  the  dynamic  power  or  muscular 
strength  is.  (See  chapter  on  Instruments  of  Precision  for 
further  illustrations.) 

Hammond  in  this  country  first  called  the  attention  of 
neurologists  to  the  thermo-electric 
calorimeter,  an  instrument  used  by  Dr. 
Lombard  for  determining  differences  of 
temperature  as  my  thermoaesthesio- 
meter    is. 

Ranney  modified  Lombard's  instru- 
ment and  described  his  modification 
in  his  very  descriptive  treatise  on 
neurology. 

The  construction  of  this  device  is 
so  simple  that  its  appearance  explains 
itself.  It  is  simply  a  graded  ther- 
mometer in  a  jar  in  which  water  at 
different  temperatures  is  poured  and 
the  jar  or  test  tube  thus  filled  is  ap- 
vw»<r  ;JVurm8.cwK«»\«ni«<«r.  plied  to  the  skin. 


CHAPTER  IX. 

EXTRA-NEURAL    OR    ADNEURAL    NERVOUS    DISEASE. 


SYSTEMIC     STATES     LEADING     TO,    PROCEEDING     FROM     AND     BLENDING 
WITH     NERVOUS    DISEASE;      MALARIA,    ERYTHROCYTES, 
THERMASIA,   THERMESTHESIA;    THEIR   EFFECTS 
ON    THE    NEURONES,     ETC. 

The  object  of  this  course  of  lectures  is  not  so  much 
to  make  you  great  experts  in  neurology,  (the  time  is  too 
short  and  life  is  too  short  for  that  and  for  the  general 
practice  of  medicine  at  the  same  time),  but  to  teach  you  to 
clearly  detect  and  intelligently  appreciate  nervous  states  in 
disease  and  the  relation  of  other  diseases  to  nervous  dis- 
ease; to  make  you  discriminating  in  searching  out  causes 
and  conditions  of  nervous  disease  and  all  the  factors  of  a 
nerve  disease  problem.  To  be  a  good  neurologist,  even  for 
the  needs  of  a  general  practice,  you  should  be  a  good  all 
around  physician  and  therefore  a  good  diagnostician, for  you 
must  differentiate  in  diagnosis,  neural  from  other  diseases 
and  be  able  to  treat  the  entire  patient  or  to  know  and 
advise  how,  where  and  when  and  by  whom  you  should  be 
assisted  in  your  treatment  of  certain  diseases.  In  nearly 
all  disease  the  nervous  system  is  more  or  less  in  evidence. 
In  some  morbid  states,  though,  the  nervous  system  is  so 
prominently  affected,  though  chiefly  in  a  secondary  manner, 
so  markedly  thus  involved,  as  to  be  designated  as  nervous 
disease.     For  instance,  locomotor  ataxia  and  general    paral- 

[90] 


91 

ysis  of  the  insane  are  supposed  to  result  from  syphilis  as 
the  chief  predisposing  factor,  to  which  some  special  brain  or 
spinal  cord  strain,  like  excessive  venery  and  prolonged  stress 
on  the  cord  or  brain,  or  other  damage  has  been  super- 
added, though  Drs.  Bruce  and  Ford  Robertson*  have  lately 
contended  that  general  paralysis  is  caused  by  gastrointes- 
tinal auto-intoxication,  resulting  from  excessive  growth  of 
micro-organisms  that  normally  inhabit  the  alimentary  tract. 
But  in  these  diseases,  changes  have  taken  place  in  the  nerve 
centers  before  the  classical  nervous  disease  appears.  In  the 
first,  the  posterior  columns  and  root  zones  of  the  spinal  cord 
have  undergone  an  indurative  tissue  change,  a  proliferation  of 
tissue  elements,  called  sclerosis.  In  the  second  the  super- 
ficial layers  of  the  grey  cortex  of  the  brain  have  become 
the  seat  of  a  subacute  inflammatory  action  with  antecedent 
and  resultant  vascular  and  brain  substance  change.  The  pial 
arteries  have  become  inflamed  and  finally  the  connective  tis- 
sue generally  and  the  psychic  neurones  and  psychomotor  neu- 
rones are  more  or  less  damaged  or  destroyed.  In  the  begin- 
ning, however,  you  have  adneural  or  extra-neural  exudates 
and  pressure  excitation,  adventitia  or  adventitious  deposits 
as  they  are  called  and  their  nervous  results.  This  is  the 
pre-paretic  stage  of  paresis  as  1  have  elsewhere  pointed  out. 
But  there  are  other  diseases  of  the  nervous  system  due 
to  syphilis  in  which  the  nervous  system  is  not  implicated  in 
the  beginning  at  least;  that  is  to  say,  that  special  part  of 
the  nervous  system  involved  in  the  causing  of  the  symptoms 
grouped  together  as  cerebral  or  other  forms  of  syphilis  of  the 
nervous  system,  and  yet  the  symptoms  are  all  nervous,  such 
as  syphilitic  arteritis  of  the  brain  and  those  forms  of  cere- 
bral or  spinal  cord  disease  which  result  from  the  adventitious 
deposits  of  syphilis,  the  exudation  of  gummata  over  vital  areas 

*See  EJiiihurg  Medical  Journal  for  December,  1901. 


92 

ol  the  nervous  centers  and  sometimes  involving  the  peripheral 
nerves,  as  in  syphilitic  neuritis.  There  is  also  alcoholic  poly- 
neuritis and  the  lancinating  pains  of  chronic  meconism  or 
opium  toxhaemia  revealed  in  chronic  opium  habitues  when  the 
repeated  doses  which  cover  up  the  poison  and  pain  are  sud- 
denly withdrawn  for  any  cause;  those  terrible  muscular  pains 
which  come  on  synchronously  with  the  exhausting  colliquative 
diarrhoea  often,  after  the  accustomed  drug  is  sensihly  and 
suddenly  reduced  to  more  than  one-half  the  accustomed  daily 
quantity  and  which  cause  the  humane  physician  to  prefer 
the  gradual  to  the  abrupt  withdrawal  of  this  terrible  drug  from 
its  unfortunate  victims, even  though  anodynes  of  the  coal  tar 
derivative  class  may  now  be  substituted  for  the  pains  of 
sudden  drug  withdrawal.  1  have  termed  this  implication  of  the 
nervous  system  in  disease  caused  by  conditions  developed 
outside  of  its  intimate  structure  and  oppressing,  by  pressure 
and  compromising  nervous  functions,  extra- neural  disease. 
My  friend,  Professor  Gowers,  whose  splendid  work  I  have 
so  often  commended  to  you  for  reading  during  your  leisure 
hours, calls  this  condition  adneural  disease.  Cerebral  apoplexy, 
cerebral  embolism,  thrombosis,  meningeal  disease,  etc.,  are 
of  this  nature,  though  sooner  or  later  the  brain  substance 
becomes  involved,  sometimes  immediately  in  some  or  all  of 
these  conditions,  except  fever  and  meningitis, and  often  these 
soon  implicate  the  brain,  though  there  may  be  delirium 
before  the  brain  is  injured  either  by  pressure  exudate  or 
destruction  of  substance.  The  disturbance  of  brain  then 
comes  from  the  fever  poisoned  and  altered  circulation. 

This  also  is  extra-neural.  But  the  symptoms  are  nerv- 
ous because  the  brain  is  disturbed  and  it  is  a  great  nerve 
center — the  greatest  nerve  center  or  aggregation  of  nerve 
centers  of  the  body;  the  highest  nerve  center,  composed 
of  the  psychic  and  psycho-motor  and  sensory  neurones. 


93 

The  recent  cranial  traumatism  that  depresses  the  skull 
and  causes  a  convulsion  which  disappears  on  trephining  or 
chiseling  and  elevating  the  depressed  bone  thereby  relieving 
the  oppressed  brain, is  of  this  nature.  But  the  resulting  struc- 
tural change  in  the  brain  beneath  is  intra-neural  disease  and 
if  the  depression  last  long  the  "epileptic  change"  may  set  in 
and  developed  epilepsy  or  other  disease  in  the  brain  and  the 
condition  is  no  longer  adneural  or  extra-neural  but  intra- 
neural also,  because  it  and  the  disease  cannot  be  removed 
by  an  operation.  When  the  first  fits  of  alcoholic  epilepsy 
come  on,  their  cause  is  extra-neural,  in  the  sense  that  we 
have  arteriole  dilation  or  vessel  spasm  and  blood  pressure; 
but  a  nervous  phenomenon,  that  of  vaso-motor  paralysis  and 
arteriole  dilatation  has  preceded, while  the  hereditary  epileptics, 
descended  from  excessively  alcoholized  parents,  are  not  ad- 
neural epileptics.  Their  epilepsia  is  called  idiopathic  because 
not  due  to  other  and  extra- neural  causes.  The  convulsions 
of  childhood  are  often  extra- neural, from  the  painful  irritation 
of  dentition,  or  from  gastro-intestinal  or  meningeal  irritation 
or  irritation  elsewhere.  Cerebral  traumatism  may  be  alto- 
gether extra-neural  at  first  simply  from  skull  depression. 

The  metastasis  of  a  facial  erysipelas  to  the  brain  is 
extra- neural  in  the  beginning,  that  is,  its  specific  toxicity  is, 
but  it  causes  delirium  and  fatal  brain  disease  as  well  as 
the  vaso-motor  nervous  disturbance  which  results  from  and 
accompanies  the  "  poison  (streptococcus  erysipelas).  The 
vaso-motor  system  as  well  as  the  streptococcus  is  concerned 
in  the  characteristic  sharply  circumscribed  cutaneous  ere- 
thema  which  goes  along  with  the  specific  inflammation  of 
the  cutaneous  and  areolar  tissue, making  this  specific  disease 
whose  tendency  to  metastatic  change  to  the  brain,  you  are 
cautioned  in  your  text- books  on  practice  to  guard  against, 
by  administering    large  doses  of    muriated  tincture  of    iron, 


94 

etc.  Erysipelas  is  as  prone  to  "strike  in"  on  the  brain  as 
parotitis  or  mumps  is  to  go  to  the  testicles  and  both  are 
delicate  spots  to  be  touched  by  specific  inflammation.  The 
gonococci,  too,  may  migrate  from  the  urethra  to  the  brain 
as  well  as  to  the  prostate,  testicles  and  joints*  and  that 
fearful  looking  swelling,  gonorrheal  orchitis  is  not  nearly  so 
formidable  as  that  condition  of  the  brain  or  other  nerve 
center  following  the  invasion  of  gonnocci  there-.  You 
may  have  a  brain  or  other  nerve  center  disease  on  your 
hands  to  treat  from  this  cause,  as  grave  as  if  it  came  from 
the  poison  of  syphilis. 

Cerebro- spinal -meningitis  and  diphtheria  and  their 
inflammatory  exudates  are  extra-neural,  but  they  give  you 
serious  nervous  diseases  to  treat,  as  grave  as  paralysis. 
The  cerebro-spinal  fever  and  post-diphtheritic  paralyses 
are  more  hopeful  in  prognosis  than  some  other  forms, because 
their  cause  is  extra- neural,  something  added  to  the  nervous 
system  and  not  always  grave,  irreparable,  nerve  tissue 
damage  as  in  that  true  intra- neural  disease — posterior 
spinal  sclerosis,  for  example.  These  poisons  develop 
abscesses  in  the  brain  and  other  nerve  centers  as 
well  as  the  joints  and  kill  often.  Gonorrhoea,  gout  or  rheum- 
atism will  interest  you  as  much  in  nervous  as  in  other 
diseases.  I  can  now  speak  much  more  hopefully, however,  in 
regard  to  staphyloccocus  or  gonococci  infection  of  the  brain 
than  my  friend, Sir  Dyce  Duckworth.  1  have  seen,  in  my  own 
practice,  many  of  these  forms  of  paralysis  make  complete 
recoveries.  I  once  had  a  young  man  under  treatment  for 
paralysis  of  the  upper  and  lower  extremities,  also  insane  and 


•See  Rheumatism  and  its  Counterfeits,  a  clinical  lecture  at  St.  Bartholomew's,  Nov. 
29th  1901.  by  Sir  Dyce  Duckworth,  M.  D,  L.L.  D.  of  London,  England,  reported  for  the 
Philadelphia  Medical  Journal  January  2,  1901.  Whatever  this  author  or  lecturer  says  or 
writes  on  the  subjects  of  gout  or  rheumatism  will  be  profitable  for  your  consideration  In  the 
management  of  those  conditions  so  often  connected  with  nervous  disorders. 


95 

deaf  and  blind,  who  recovered  everything  but  his  sight  in 
six  months  from  the  onset  of  his  post  cerebro-spinal-men- 
ingeal  malady.  He  became  robust  and  grew  to  mature 
manhood  in  the  blind  asylum  here,  where  he  learned  one  of 
the  trades  of  that  benevolent  institution.  Autotoxhaemia 
or  self  blood  poisoning  is  a  fruitful  source,  as  you  are  ready 
to  surmise  from  what  1  have  already  said  of  extra- neural 
or  adneural  disease.  Sydenham  and  Scudamore,  who  long 
ago  were  authorities  on  gout,  pointed  this  out  and  even 
Hippocrates  and  Shakespeare.  The  great  English  dram- 
atist made  many  other  sagacious  medical  observations. 
"The  Scripture  saith  the  blood  is  the  life"  as  physiology 
teaches,  and  that  immortalized  name  in  the  annals  of  med- 
ical literary  fiction,  Sangrado,  who  purged  and  bled  and 
filled  his  patients  with  water,  (not  normal  salt  water  solu- 
tions now  so  valuable  in  states  of  depression  hypodermic- 
ally)  regarded  all  disease  as  extra -neural.  He  believed 
in  the  value  of  a  flush  in  physic,  like  my  friend  Dr. 
Love  who  addressed  you  the  other  day,  and  a  flush  is 
a  good  thing  if  you  know  how  to  play  it  in  the  game  of 
therapeutics  where  the  integrity  and  life  of  nerve  centers 
are  at  stake.* 

These  adneural  affections  promise  more  hope  of  recov- 
ery than  many  other  forms.  When  you  come  across  them 
treat  the    patient    constitutionally  all    over,  remembering  in 

*Since  these  lectures  were  delivered  my  friend,  Dr.  George  F.  Butler  of  Alma,  Michi- 
gan, in  a  recent  able  contribution  in  that  indispensable  medical  periodical,  the  Journal  of  the 
American  Medical  Association,  which  you  all  must  have  when  in  practice,  opportunely  quotes 
from  Sydenham  on  this  very  subject  and  makes  some  further  forceful  and  pertinent  points 
which  1  commend  to  your  reading.  Sydenham  pointed  out  that  suppressed  gout  ("that  is, gout 
without  joint  expression.)  exercised  marked  influence  on  the  constitution.  The  body,  he 
remarks,  "is  not  the  only  sufferer  and  the  dependent  condition  of  the  patient  is  not  his  worst 
misfortune.  The  mind  suffers  with  the  body,  and  which  suffers  most  is  hard  to  say.  So  much 
do  mind  and  reason  lose  energy  as  energy  is  lost  by  the  body, so  susceptible  and  vascillating 
is  the  temper,  such  a  trouble  is  the  patient  to  others  as  well  as  himself,  that  a  fit  of  gout  is  a 
fit  of  bad  temper.  To  fear,  anxiety  and  other  pass'ons,  the  gouty  patient  is  a  continual 
victim;  whilst  as  the  disease  departs,  the  mind  regains  tranquility."  He  also,  as  Butler 
notes,  "pointed  out  that  gout  affected  the  throat,  heart  and  lungs  as  in  asthma." 


06 

your  therapeutics  the  causes  that  have  left  the  neural 
sequences  and  let  your  motto  be  "nil  desperandum." 

These  antecedent  systemic  diseases  which  result  in 
serious  sequelae  of  neural  development  and  grave  systemic 
nervous  diseases  show  the  importance  of  an  all  around 
extensive  knowledge  of  the  operations  of  disease  and  the 
necessity  of  knowing  all,  in  order  to  work  wisely  and  well 
on  a  part,  in  the  practice  of  medicine.  The  nervous  system 
in  some  of  the  divisions  is  involved  in  nearly  all  altered 
physiology.  Conditions  such  as  we  are  considering  and 
conditions  such  as  1  have  hinted  at  and  other  morbid 
phenomena  which  I  might  mention,  did  time  permit,  and 
some  of  which  are  yet  so  important  that  1  shall  have  to 
refer  to  them,  that  led  the  great  Dr.  Cullen  to  say  that 
from  all  he  could  see  of  the  movements  of  disease  in  the 
human  organism  they  might  all,  in  a  manner,  be  called 
nervous,  or  words  to  that  effect.  Extra- neural  nervous 
diseases  also  have  their  origin  in  nerve  center  impli- 
cation elsewhere  than  at  the  place  of  disease  manifestation 
in  the  system,  as  in  the  changes  due  to  disease  damage 
and  implication  of  vaso-motor  and  heat  centers  in  the  brain 
and  those  ganglionic  changes  that  cause  disease,  changes 
and  disordered  action  in  the  viscera,  fourth  ventricle 
changes  in  glycosuria,  and  the  vagus  center  changes  there 
causing  cardiac,  arythmia,  tachycardia,  etc. 

One  other  subject  is  so  important  in  the  understanding 
and  treatment  of  nervous  diseases  of  the  central  Mississippi 
valley  countries  of  the  United  States,  the  west,  northwest 
and  south,  whose  waters  wash  their  way  to  the  Gulf  of 
Mexico  through  the  great  Father  of  Waters,  that  1  must  touch 
it  briefly  before  I  close.  That  subject  is  malaria  in  connection 
with  nervous  disease.  This  too  gives  us  many  extra-neural 
nervous  conditions  to  consider. 


07 
PLASMODIUM  MALARIA,  ERYTHROCYTES, THERMASI A,  ETC. 

The  malarial  Plasmodium  which  attacks  the  erythrocytes 
or  fully  developed  red  corpuscles  of  the  blood,  as  distin- 
guished from  the  erythroblasts  or  rudimentary  or  nucleated 
red  corpuscles  will  claim  your  attention  many  a  time  and 
oft  in  practice.  It  is  interesting  to  note  the  selective 
affinity  of  this  Plasmodium,  like  an  endowed  intelligence,  for 
the  full-grown  red  corpuscle  over  the  erythroblast,  and  it 
will  interest  you  to  watch  carefully  the  wicked  work  of  the 
malarial  parasites, developing  the  remittent  and  different  forms 
of  intermittent  fever,  as  you  may  see  them  displayed  where 
most  of  you  live,  for  these  varieties,  the  remittent,  the  quo- 
tidian, tertian  and  quartan  intermittents,  depend  for  their 
manifestation  on  the  manner  in  which  the  nervous  system 
responds  to  the  presence  of  malarial  germs  in  the  blood 
and  to  the  form  of  this  pernicious  parasite  of  Laravan. 
You  will  see  in  those  excellent  plates  of  C.  E.  Simon  which 
Duane  has  put  in  that  useful  little  dictionary  whose  defini- 
tions I  like  so  well,  though  1  do  not  always  approve  his 
pronunciations,  very  impressive  illustrations  of  the  perni- 
cious work  of  this  poisonous  parasite  group,  whose  mischiev- 
ous and  destructive  work  on  the  nervous  system,  central 
and  peripheral,  has  not  all  been  as  yet  recorded.  Look  out 
for  it  in  your  practice.  In  spring  and  autumn  the  rains 
fill  the  porous  earth  and  the  malaria  comes  out  to  cause 
the  aestivo- autumnal  fevers. 

It  is  your  enemy  and  the  enemy  of  your  patient,  where 
or  near  where  many  of  you  live.  It  is  the  old  marsh  miasm 
of  Elliotson,  Watson  and  the  other  older  writers,  now  trans- 
lated into  the  "bugs  of  the  bogs,"  as  they  call  them  in 
Texas.  Its  or  rather  their,  home  is  in  the  marshes,  bayous, 
the  watery  wastes, flats  and  sloughs, or  where  the  soil  is  wet 
and  porous  and  often  broken  and  where   the  culex  mosquito 


98 

makes  his  haunt  and  vegetable  decay  goes  on,  and  where 
you  may  feel  at  night  time  the  sting,  if  you  do  not  hear  the 
merry  murderous  song  of  this  festive  anophile.  It  does  not 
abide  altogether  in  the  marshes  but  migrates  to  the  blood 
of  man.  Mosquitoes  carry  it.  Perhaps  other  insects  do,  the 
gnat  and  other  culices,  and  it  is  wafted  on  the  winds  of 
eventide  and  the  night  time  after  the  sun  is  set.  It  gets 
into  man's  body  through  air  and  water  and  is  the  null  air 
constituent,  carried  by  the  malarial  water  and  whence  the 
term  malaria.  It  gets  into  the  body  and  sporulates  there, 
breaking  down  the  red  blood  corpuscles; it  destroys  the  eryth- 
rocytes, as  the  learned  bacteriologists  tell  us,  and  when 
the  red  blood  corpuscles  are  being  destroyed,  the  beginning 
of-  the  end  has  begun  with  man.  Disintegrated  blood 
corpuscles  cause  anaemia,  simple  at  first  and  finally  per- 
nicious, causing  symptoms  resembling  typhoid,  causing  vital 
depression  in  other  forms,  anaemic  neurasthenia,  neuralgia, 
neuritis,  vaso-motor  paralyses  and  its  sequent  paralysis,  the 
paralyses  of  malarial  congestion  and  toxhaemia.  The  chill 
and  fever  and  reactionary  sweating,  congested  and  disordered 
spleen,  liver,  kidney,  bowels;  the  jaundice,  hematemesis, 
haematuria,  etc.,  and  sometimes  albuminuria  of  profound  ma- 
larial toxhaemia,  are  not  the  only  mischief  malaria  makes 
with  man,  as  you  can  see,  for  from  this  poisonous  agent  may 
come  delirium  and  coma,  which  are  nerve  center  symptoms 
like  the  chill,  etc.  It  may,  in  other  ways,  attack  tne  brain, 
spinal  cord  and  peripheral  nerve  centers  (the  ganglionic) 
pigmenting  them  after  sporulation,  (though  pigmentation  is 
not  always  nervous  disease),  and  marking  man  for  destruc- 
tion in  many  ways,  through  nervous  disease  not  yet,  by 
common  professional  consent,  attributed  to  this  potent 
poison.  So  that  unless  you  come  skillfully  to  the  rescue 
with  timely  and  adequate  doses  of  quinine  and  other    anti- 


99 

malarial  and  blood  reconstructives  that  kill  these  parasites, 
destroy  these  microscopic  "bugs  of  the  bogs,"  rebuild  the 
blood  and  save  and  restore  the  damaged  nerve  centers,  and 
prophylactics  against  malaria,  your  patients  after  a  time 
may  die  of  the  consequences  of  malarial  poisoning.  It  has 
been  the  practice  on  the  plantations  of  the  south  for  more 
than  half  a  century  to  use  large  doses  of  quinine  and  other 
salts  of  cinchona,  dogwood  bark,  salicin  from  the  willow, etc., 
as  preventive  of  malarial  disease,  though  Kock  speaks  lately 
on  the  subject  as  though  it  were  yet  new.  The  old  doctors 
of  the  marshes  and  bayous  of  the  west  and  south  can  tell 
you  well  the  old,  old  story  of  malaria  and  how  they  warred 
against  it  with  quinine,  arsenic  and  other  prophylaxis.  You 
must  kill  the  parasitic  enemy,  cast  out  the  devil  of  destruc- 
tion and  repair  the  damage  done  to  the  organism, as  well  as 
to  the  blood,  in  order  to  save  your  patient's  nervous  system, 
involved  in  the  onslaught  of  the  parasitic  invader.  Neurotic 
and  haematic  reconstruction  will  help  to  save  the  imperiled 
nerve  centers  from  damage.  So  will  bromide  of  ammonium, 
judiciously  used  and  the  cinchona  alkaloids  and  salicin, 
encalyptus,  dogwood  bark,  etc.,  liberally  employed,  and 
mercurials  judiciously  given,  will  drive  out  and  destroy  the 
enemy.  You  must  give  attention  to  general  medicine  and 
therapeutics  in  order  to  make  a  good  neurologist, as  well  as  to 
general  pathology  and  diagnosis. 

Your  study  of  the  malarial  Plasmodia  in  connection 
with  their  influence  on  the  nervous  system  will  give  these 
parasites  of  quartan  and  of  aestivo- autumnal  fever  an  addi- 
tional interest  and  you  will  pay  more  attention  to  the  chair 
of  clinical  medicine  and  pathology  after  these  hints  as  to 
the  neuropathic  potentiality  of  the  Plasmodium  malaria 
given  you.  The  culex  mosquito  and  perhaps  the  culex 
pipens  will  interest  you.     For  it  has  been  found  that  there 


100 

is  a  female  in  the  case  and  that  the  female  culex  mosquito 
here,  as  other  females  elsewhere,  is  capable  of  doing  much 
damage  to  mankind. 

While  considering  extra- neural  affections  it  is  well  to 
note  in  this  connection,  those  hyperthermal  or  hyperthermo- 
haemic  states  and  hypo  or  athermo  or  athermohaemic  (hyper 
meaning  +  while  Otpw  signifies  heat  wherever  you  may  come 
across  them  in  your  reading),  neural  effects  such  as  sunstroke 
and  brain  inflammations  from  external  violence  and  certain 
febrile  diseases  on  the  plus  side  and  the  rigors  and  the  chills 
on  the  minus  side, which  sometimes  precede  poliomyelitis  ante- 
rior, as  they  do  pneumonia  and  as  they  may  follow  the  hypo- 
thermia of  the  febrile  crises  in  typhoid  fever.  These  affect  the 
nerve  centers  as  well  as  the  blood  and  cause  phenomena  that 
are  called  nervous  symptoms. 

Thermasiae  (0ep/xaaLa)  heat)  the  opposite  of  thermaes- 
thesia.,  the  latter  being  a  paralysis  of  heat  perception,  are 
also  to  be  studied  by  you  in  the  understanding  and  mastery 
of  nervous  disease. 

FIG.   45. 


Cut  showing  relation  of  blood  vessels  to  groups  of  neurones  and  how 
abnormal  vascular  conditions  may  develop  morbid  states  of  nerve  centers. 
The  cut  snows  normal  conditions. 


FIG.  46 


Intraneural  Changed  Multiple  Neuritis  and  Local 
Nerve  Traumatism.  Lomi tub inal  motion. 


FK..   47. 


FIG.  48. 
£xtra  ttcwvaL  Uervous  P isease.  o^ \>raVn  - 


FIG.  49. 

Axsec^ae  o^cxXx^^  txe«.vo»V  o»la'm.  froitv- 
Scarce  ^cvV\s.^'s  book  ow"Q.tcuic>a*  <x>yv& 

-'■>*§^ 


*i>(vfc    oervVeoA    vevXeVsTeae 


FIG.   50. 


A,  A,  A,  A,  area  of  blood  clot.  The  cord  is  here  shown  enclosed  in  its 
dural  sheath.     The  projections  are  the  spinal  nerve  sheaths. 

The  smaller  cut  shows  section  of  cord  and  spinal  nerves  with  the  dura 
drawn  aside. 


CHAPTER  X. 

EXTRA-NEURAL    OR  ADNEURAL    NERVOUS    DISEASE. 


EXTRA-NEURAL  NERVOUS   DISEASE;     CHROMATIC  AND  ACHROMATIC  NEU- 
RONES,  CHROMATOLYSIS,   THERMAL   CHANGES   IN   THE   NEURONES, 
BRAIN     NEURONES      AS     HEAT      CENTERS,     ADNEURAL      HEAT 
CHANGES  OF  NEURONES,  MARINESCO  AND  LUGARO'S 
LAW  OF  MORBID  NEURONE  CHANGE,  REFLEX 
PHENOMENA  AND   THE   NEURONES. 

While  traumatism  to  the  brain  and  spinal  cord  and 
disease  impression  on  the  heat  centers,  cause  directly  induced 
nervous  disease,  the  over-heating  of  the  neurones  and 
morbid  changes  in  them  may  take  place  from  superheating 
of  the  blood;    i.  e.,   by  hypohsemothermia,  as  in  sunstroke. 

Coup  de  soliel  may  therefore  be  either  an  intra-neural 
or  extra- neural  nervous  disease;  according  to  the  degree  to 
which  the  neurones  are  involved  and  according  to  the  man- 
ner in  which  it  may  be  brought  about,  whether  by  the 
direct  rays  of  a  broiling  sun  overheating  directly  the  neu- 
rones of  the  brain— or  by  the  long  continuance  of  high 
temperature,  or  it  may  be  both,  i.  e.,  brought  about  by 
excessive  heat  of  blood  and  by  direct  overheating  of  the 
cerebral  neurones  combined  and  heat  centers. 

When  appreciably  grave  nervous  disease  results  from 
the  influence  of  extra- neural  conditions,  it  is  the  achromatic 
portion  of  the  neurone,  the  nucleus  and  motor  segments  of 
the  cells,  that  appear  to  be  mostly  affected.     The  chromatic 

[101] 


102 

or  chromophile  or  stain- receiving  portions,  if  influenced,  do 
not  seem  to  make  the  subject  so  markedly  interesting  to 
the  clinical  neurologist.  Here  is  a  postgraduate  theme  for 
you.  We  shall  however  ask  you  no  green  room  questions 
on  this  subject. 

Here  as  elsewhere  some  influences  effect  only  appear- 
ances, others  do  the  real  thing.  It  is  when  the  non-coloring 
element  of  the  cell  or  neurone  is  involved  that  the  chief 
real  harm  is  done  to  the  nerve  centers.  Why  this  is  so 
cytology  does  not  yet  fully  enlighten  us.  It  is  ready  to 
learn  from  you  as  the  oncoming  cyto-scientists  and  cyto- 
savants  of  the  profession. 

LUGARO'S  AND   MARINESCO'S    LAW  OF  MORBID 
NEURONE   CHANGE. 

Now  gentlemen,  most  authorities  say  that  the  fibrillar 
portion  of  the  achromatic  substance  subserves  the  function 
of  conducting  the  nervous  waves.  Cajal,  Lenhasseck,  Rob- 
ertson, Nissl  and  some  others  consider  that  we  are  not  war- 
ranted in  attributing  the  performance  of  functions  to  the 
fibrils  alone.  The  non-organized  portion  of  the  achromatic 
substance  is  believed  by  Marinesco  to  be  the  seat  of  intense 
chemical  phenomena  and  of  such  importance  for  the  nervous 
element  as  to  be  appropriately  designated  the  trophoplasm, 
that  is  the  plasma  of  nutrition.  That  this  substance  is  the 
seat  of  important  metabolic  changes  is  amply  confirmed  by 
other  observers,  more  especially  by  Guiseppi  Levi  from  his 
study  of  the  fuchsinophile  granules.  According  to  Van- 
gehuchten,  Nissl,  Lugaro,  Lenhasseck, Cajal  and  many  others 
the  chromophile  substance  of  the  protoplasm  is  a  material 
of  reserve,  destined  to  serve  for  the  nutrition  of  the  nervous 
element.  Marinesco  believes  it  serves  to  augment  the 
difference  of  potential  of  the  centrifugal  nerve  wave.* 

♦Ford  Robertson,  Text-book  of  Pathology  and  Nervous  and  Mental  Diseases,  page 
222,  edit.,  1900. 


103 

The  cell  body  contains,  as  you  know,  the  nucleus  and 
nucleolus  and  is  the  trophic  center  for  the  whole  cell 
element  as  proved  by  ample  experiment  which  cannot  be 
entered  upon  today.  Structural  changes  accompany  modi- 
fication of  function  in  the  cell  and  vice  versa,  functional 
changes  follow  structural  changes  of  the  cells  as  I  have 
already  shown  you.  "When  the  energy  of  the  cell  is 
exhausted  by  prolonged  or  excessive  activity  the  cell  body 
and  the  nucleus  are  distinctly  diminished  in  volume,  the 
chromophile  substance  of  the  cell  plasm  or  cytoplasm 
is  small  in  amount  and  appears  diffusedly  granular. 
During  normal  activity  the  chromophile  substance  is  uti- 
lized by  the  cell  and  slowly  diminished  in  quantity," 
says  Ford  Robertson  farther.  This  would  seem  to  me 
to  tend  to  establish  the  disintegration  of  the  chromophile 
substance  correlative  with  cell  function  and  tend  to  show 
that  it  nevertheless  has  considerable  to  do  with  the  poten- 
tiality of  the  cell  fuchsinophile  granules  of  Levi.  The  nucle- 
olus undergoes  an  increase  in  volume  and  the  particles  of 
chromophine  adherent  to  it  consequently  tend  to  become 
more  elongated.  During  rest  the  chromophile  substance 
gradually  accumulates  again,  the  fuchsinophile  granules 
diminish  in  numbers  and  the  nucleolus  assumes  a  smaller 
volume." 

Thus  you  see  that  whatever  may  be  the  cause  or 
causes  operating  to  develop  nervous  disease,  whatever  cause 
or  gross  change  takes  place  in  nerve  centers  or  periphery 
through  morbid  alterations  in  blood  supply  or  quality  or  in 
the  environment  of  the  nerve  centers,  or  from  traumatism  or 
other  external  causes,  it  is  the  abnormal  impression  upon 
and  the  morbid  response  of  the  neurones,  or  glial  connec- 
tions and  their  morbid  expression,  that  gives  us  generally 
the  phenomena  of  nervous  diseases.     Either  the  mesoglia  or 


104 

the  cytoplasm  itself,  i.  <\,  the  >:ell  plasm  pFoper  of  the  neu- 
rone either  in  its  nucleus,   nucleolus,  neuraxone,  dendrite,  or 

gemmule,  receives  and  responds  in  abnormal,  crippled 
fashion  to  the    morbid    touch    of    its    environment,  whether 

this  morbid  touch  be  a  germ,  traumatism  or  a  blood 
element  altered  in  quantity,  quality  or  toxically  depraved, 
causing  a  change  in  the  blood  quality. 

Persistent  malarial  poisoning,  chronic  alcoholism,  re- 
peated attacks  of  grip,  the  opium  taking  habit,  habitual 
chloral, cocaine, cannabis  indica  and  other  narcotic  drug  habits, 
all  of  which  are  toxic  to  the  neurones  and  in  the  beginning 
extra- neural,  being  impressions  first  made  through  the  blood, 
should  have  much  of  your  thought  in  practice.  The  medical 
practitioner  should  be  on  the  lookout  for  these  disturbances. 
Nerve  tire,  brain  fag,  the  assaulting  and  weakening  of  the 
neurones  are  the  beginnings  of  trouble  and  lead  to  grave  con- 
sequences. We  have  here  toxic  neurones  and  nerve  centers 
to  deal  with.  As  brain  fag  and  nerve  strain  precede  Bright's 
disease  and  dyspepsia  ordinarily,  and  complicate  other 
troubles,  so  do  these  extra  or  adneural  states  of  the  blood 
often  precede  pronounced  nervous  disease.  The  blood  may 
be  the  life  or  death  of  the  nerve  centers  and  vice  versa  the 
life  or  death  of  nerve  centers  may  be  the  life  or  death  of 
the  blood  and  of  the  organs  the  blood  nourishes.  The  moral 
of  this  in  medical  practice  is — take  care  of  the  neurones  and 
of  the  blood  as  well  as  of  the  environment  of  your  patients. 

The  difference  therefore  between  extra  or  adneural  and 
intra -neural  nervous  disease  is,  that  in  the  former  the  lesion 
of  the  nerve  cell  or  some  part  of  the  neurone  is  secondary 
and  functional  to  the  extraneous  influence  imposed  upon  it, 
while  the  primary  lesion  has  its  beginning  in  the  nerve  cell 
or  in  its  proliferations.  Intra-neural  may  also  follow  extra- 
neural  lesion     because    the    extra- neural    embarrassment  of 


105 

the  nerve  or  nerve  center  causes  intra- neural  change  to 
sooner  or  later  occur,  as  when  nerve  atrophy  follows  pres- 
sure or  starvation  of  the  nerve  or  neurone  or  nerve  center 
group  of  neurones.  There  is  an  obvious  difference  too,  in 
the  gravity  and  permanence  of  the  effect  resulting  from 
extra  and  intra- neural  change,  especially  early  in  the  dis- 
ease. The  degenerations  begin  more  tardily  from  extra- 
neural  nervous  disease  and  are  often  more  readily  removable, 
as  in  the  adneural  changes  of  syphilis,  as  I  have  already 
told  you.  Syphilitic  nervous  disease  may  be  both  extra 
and  intra- neural.  Marinesco*  has  recognized  this  fact.  He 
says,  "secondary  degeneration  of  the  nerve  cell  is  uniform, 
beginning  with  disintegration  of  the  chromatic  substance  in 
the  neighborhood  of  the  axis  cylinder  or  neuraxone  and 
extending  to  the  rest  of  the  neurone.  The  cell  may  repair, 
or  it  may  atrophy  and  disappear.  In  primary  degeneration 
the  alterations  are  variable,  grave  and  many."  The  achro- 
matic or  non-color  change  substance  is  likely  to  become 
affected  and  this  may  make  repair  impossible  and  seal  the 
fate  of  your  patient. 

The  pathology  of  the  neurones,  as  I  have  already  told 
you,  will  interest  you  in  adneural  as  in  other  morbid  nerve 
cell  changes.  They  have  been  a  never  ceasing  source  of 
interest  to  me  and  the  distinguished  observer  and  author 
whom  I  have  commended  to  you  will  make  the  subject 
entrancing  to  you  in  your  vacation  days.  He  quotes  from 
Lugaro,  who  has  summarized  the  effects  of  toxic  agents  on 
the  nerve  cells,  much  more  than  I  have  time  to  read  you 
or  you  to  listen,  but  I  will  give  you  enough  to  whet  your 
appetite  and  in  the  summertime  you  may  read  the  rest.t 

*  G.  Marinesco  Les  Polyneuritis  en  rapport  avec  les  Theorie  des  Neurones,  Bui.  Med. 
1895,  n  97,  quoted  by  Ford  Robertson. 

tVide  Ford  Robertson  p.  225,  Lugaro,  Recenti  Progressi  del'  Anatomia  de  Systems 
Nervosa  in  Rapport  alia  Psichologia  et  alia  Psichiatria,  Riv.  de  Patol.  Nerv.  e  Ment.,  1899 
11-12. 


106 

And  those  oi  you  who  have  mastered  the  Italian  lan- 
guage will  find  floods  ol  light  thrown  on  the  fine  anatomy, 
physiology  and  pathology  of  the  nervous  system  by  our 
wonderfully,  industrious  and  intelligent  Italian  confreres 
Levi,  Marinesco,  Lugaro,  Chiozzi  and  others. 

These  extra- neural  influences  affect  the  nerve  centers 
through  impression  on  the  neurones,  their  neurites,  den- 
drites, gemmulae,  neuroglia  or  mesoglia.  They  affect  them 
morphologically  by  pressure  or  chemically,  as  poisons  do,  or 
by  more  or  less  rapid  transformation  of  the  physiological 
function  of  the  neurone  into  morbid  action  by  ajiatomical 
change,  and  anatomical  change  in  a  nerve  cell  is  usu- 
ally preceded  by  some  sort  of  molecular  change.  Now 
for  example  the  sequellas  of  typhoid  fever,  which  may  be 
either  a  delirium  or  typho- mania  (psychic  neurones),  a 
paralysis  (psychomotor  neurones),  or  neuritis  or  neuralgia 
(peripheral  neurones). 

There  are  some  influences  which  affect  one  part  of  the 
cell  without  immediately  at  least  affecting  the  other  parts 
of  it.  For  instance,  temporarily  compressing  the  abdominal 
aorta,  as  Lugaro  has  shown,  will  cause  a  color  change 
(chromotolysis)  in  the  chromophile  or  chromatic  part  of  the 
neurone,  which  color  change  in  the  cell  will  persist  for 
some  time  after  the  cause  is  withdrawn  and  the  functional 
disturbance  has  ceased.  Artificially  induced  hypothermia 
and  melonitril  poisoning  will  do  the  same.  Other  slow 
poisonings  will  do  the  same  and  similarly  affect  the  chro- 
mophile elements  of  the  neurone  while  fatal  doses  of 
chloroform  or  ether  do  not  change  the  chromophile  part  of 
the  cell,  as  Lugaro  has  shown. 

The  chromatic  part  of  the  cell  seems  to  be  concerned 
in  the  metabolisms  and  to  be  affected  every  time  they  are 
disturbed.     Says  Ford  Robertson,  "they  play  a  very  impor- 


107 

tant  role  in  the  functional  metabolism  of  the  nervous 
element,  its  alterations  are  a  direct  index  of  a  nutritive 
alteration  and  that  function  will  be  entirely  suppressed 
when  the  structural  dispositions  of  the  achromatic  (or  non- 
coloring)  part  of  the  cell  which  seems  more  strictly  related 
to  nerve  conduction,  are  altered  morphologically  or  chemic- 
ally." Among  the  new  problems  therefore  in  the  pathology 
of  the  neurone  is  Lugaro's*  and  Marinesco's  law  for  them, 
now  generally  accepted  as  true  by  expert  cytologists,  to 
which  1  have  already  referred  and  which  1  repeat  to  impress 
you, and  that  is  that  changes  in  chromatic  cytoplasm, or  color 
preferring  cell  tissue  or  chromophile  plasma,  as  it  is  differ- 
ently termed,  represent  the  reaction  of  the  neurone  to  the 
cell  coloring  influence  that  disturbs  the  neurone  and  color 
causing  changes  in  the  neurone. 

These  chromatic  changes  in  the  neurone,  and  the  same 
is  true  in  neurology  as  in  psychiatry,  are  reparable,  while 
achromatic  changes  in  the  neurone  are  irreparable  and  degen- 
erative. Robertson  quotes  this  law  with  approval  in  his 
excellent  discussion  of  the  morbid  conditions  of  nerve 
cells  and  from  whom  I  would  like  to  read  in  extenso  did 
time  permit.  Remember  1  have  commended  this  splendid 
author  for  reference  during  your  leisure  respite  from  the 
exacting  demands  of  this  course.  It  will  prove  a  source  of 
great  enlightenment  to  you  on  the  relation  of  cell  pathology 
to  mental  diseases  especially  and  also  of  cytopathology  to 
neurology.  Now  this  is  the  conclusion  of  the  matter. 
Disease  is  impressed  on  the  neurone,  the  neuroglia  or 
mesoglia  of  nerve  centers  through  either  chemical  or 
mechanical  or  morphological  change.  These  neurones  have 
chromatic  and  achromatic  parts  and  are  said  to   be  chromo- 

*Nuovi  data  e  nuovi  problemi  nella  patologia  della  cellula  nervosi,  Revista  ii  Palologia 
Nervosi  e  mentali.  1896.  f  8.      Vide  ante  from  Robertson. 


108 

phile  or  achromophile,  chromatic  or  achromatic;  that  is,  to 
have  either  a  color  selection,  love  or  color  aversion  or 
repulsion  and  love  is  an  affinity  in  cytology,  as  well  as  in 
psychology,  and  chromophile  cytoplasm  or  neurone  changes 
arc  capable  of  regeneration  and  repair,  while  achromophile 
changes  in  cytoplasm  are  degenerate  and  irreparable  and 
this  reparability  and  non-reparability  of  the  different  parts 
of  the  neurone  is  Lugaro  and  Maranesco's  law  and  by  this 
law  good  diagnostic  judges  pronounce  the  verdict  of  life  or 
death  to  nerve  element  and  they  declare  prognoses  of  chron- 
icity  or  death  to  your  patient  in  the  grasp  of  a  nervous 
affection.  It  is  a  valuable  criterion  for  necroscopic  conclu- 
sions in  the  cytopathology  of  neurology  and  psychology. 

That  brilliant  observer,  Ford  Robertson, to  whom  you  note 
I  love  to  refer  as  I  do,  to  the  masterly  Maudsley  in  matters 
physio-psychical,  (vide  p.  240)  unconsciously  touches  upon  the 
subject  of  extra- neural  nervous  disease  without  especially 
mentioning  it  in  the  following  words  under  the  head  of 
morbid  conditions  of  the  nerve  cells:  "It  is  necessary  to 
distinguish  clearly  between  special  diseases  of  the  nerve 
cell,  and  mere  types  of  morbid  change  that  may  be 
observed  to  affect  it.  Changes  such  as  chromatolysis,  vac- 
uolation  and  the  pigmentary  degeneration,  cannot  be 
regarded  as  diseases  of  the  nerve  cell,  but  only  as  types  of 
morbid  alteration  occurring  in  several  forms  of  disease.  At 
present  the  only  definite  diseases  of  the  nerve  cell  that  are 
known  are  primary  degeneration  (in  which,  however,  future 
research  will,  without  doubt,  enable  us  to  recognize  various 
distinct  forms  and  secondary  degenerations)."  I  do  not, 
however,  concur  with  him  in  regard  to  vacuolation. 
Vacuolation  may  be  a  structural  intra-neural  as  well  as  neu- 
roglial change.  It  is  destruction  of  nerve  cell  or  nerve  ele- 
ment, or  of  the  connecting  neuroglial  framework  of  the  neu- 


109 

rone,  and  this  is  entitled  to  be  regarded  as  structural  nervous 
disease.  If  an  egg  basket  is  destroyed  while  it  holds  the  eggs 
in  place  as  the  neuroglia  hold  the  neurones  in  place, the  eggs 
are  apt  to  be  displaced  and  damaged,  if  not  destroyed.  The 
neurones  must  similarly  suffer  in  their  glial  framework  under 
vacuolating  change,  as  in  that  singular  paralytic  spinal  nerv- 
ous disease,  syringomyelia,  whose  pathology  is  revealed  in 
gliosis  or  gliomatosis  or  abnormal  proliferation  or  hyperplasia 
of  gliomatous  tissue  and  vacuolation,  a  disease  whose  path- 
ology I  have  sometimes  curtly  called  in  the  clinics  holes  in 
the  spinal  marrow,  as  its  Greek  origins  signify.  Syrinx,  o~vpi.yt 
a  tube  or  canal  and  myelos,  /^eAos,  marrow,  a  chronic,  painful, 
parassthetic,  thermo-anaesthetic  hollowing  out  disease  of  the 
spinal  cord  with  trophic  changes  in  skin,  joint  and  bones, 
which  we  will  discuss  more  fully  later  on.  Likewise 
porencephalia. 

"Chromatolysis,"  is  a  color  change  or  disintegration  of 
chromophile  cytoplasm,  according  to  that  eminent  cytological 
authority,  Marinesco,  introduced  by  Robertson,  who  defines 
it  as  a  disintegration  of  the  chromatic  particles  of  the  pro- 
toplasm, breaking  up  the  aggregations  of  the  granules  that 
form  the  Nissl- bodies  and  gradual  disappearance  of  the  indi- 
vidual granules,  accompanied  in  transition  stages  by  their 
diminished  affinity  for  basic  dyes.  But  it  has  been  frequently 
used  in  a  wider  and  more  general  sense,  namely,  to  indicate 
the  whole  series  of  changes  in  the  constituent  elements  of 
the  cell,  of  which  dissolution  of  the  chromatic  particles  is 
merely  the  first  that  is  recognizable.  Its  employment  in  this 
wider  sense  can  only  lead  to  confusion,  and  ought  to  be 
abandoned  he  says;  but  the  clinicians  and  pathologists  will 
continue  to  give  it  this  wider  meaning  while  the  cyto-micro- 
scopists  may  restrict  its  pure  cytological  description.  Van- 
gehuchten  employs  the  term   "chromolysis"  as  a  synonym. 


110 

Chromatolysis  or  chromolysis  has  already  been  indicated.  It 
accompanies  primary  and  secondary  degeneration  in  almost 
all  their  forms.  Moreover  it  occurs  as  a  physiological  con- 
dition in  fatigue  of  the  nerve  cell;  as  tar  as  can  be  deter- 
mined by  microscopical  examination,  the  chromophile  part 
of  the  cytoplasm  is  the  most  sensitive  constituent  of  the 
nerve  cell  under  abnormal  nutritional  conditions.  (It  is 
both  primary  and  secondary  in  cell  change).  The  exact 
mechanism  of  the  production  of  chromatolysis  in  pathological 
states  is  little  understood.  Probably  in  certain  instances 
there  is  especially  an  increased  consumption  of  the  chromo- 
phile substance,  in  others  especially  an  arrest  of  its  func- 
tion." 

"Chromatolysis  has  been  observed  in  the  human  sub- 
ject in  a  very  large  number  of  different  morbid  conditions. 
Indeed,  it  is  now  known  that  it  occurs  in  some  degree  in  a 
proportion  of  the  nerve  cells  of  almost  every  individual  on 
the  face  of  the  earth  dying  a  natural  death.  Even  in  non- 
nervous  diseases  it  is  very  commonly  a  very  extensive  and 
well  marked  accompaniment  of  morbid  change  in  the  cells 
of  the  cerebral  cortex,  spinal  cord,  etc.  In  such  cases  it  is 
to  be  attributed  to  the  action  of  toxic  substances  generated 
in  the  course  of  the  particular  disease,  to  pyrexia,  terminal 
auto-intoxication  or  local  vascular  lesions.  At  the  same 
time  abundant  evidence  has  now  been  accumulated  of  the 
special  incidence  of  chromatolysis  in  various  forms  of  nerv- 
ous disease.  But  in  these  cases  it  is  generally  accompanied 
by  other  morbid  alterations  in  the  cells  which  at  once  give 
to  the  pathological  picture  a  much  graver  aspect." 

"Marinesco  has  applied  the  term  'achromatosis'  to  a 
change  which  consists  especially  in  an  extreme  degree  of 
chromatolysis — complete  disappearance  of  the  chromophile 
elements  of    the    cytoplasm.     In    preparations  stained    with 


Ill 

polychrome  blue,  the  cytoplasm  appears  pale  or  absolutely 
colorless,  resembling  dull  glass.  He  has  observed  this  con- 
dition of  achromatosis  in  the  cells  of  the  anterior  root  after 
evulsion  of  spinal  nerves  and  in  those  of  the  cerebral 
cortex  in  diabetes  insipidus,  leprosy,  pellagra,  etc.  It  corre- 
sponds morphologically  to  the  extreme  degree  of  the  lesion 
observed  to  attend  experimental  elevation  of    temperature." 

This  discussion  of  chromatolysis  is  a  little  more  complex 
for  advanced  students  of  cytology  than  we  have  presented 
it  and  you  will  find  much  in  the  same  line  to  interest  you 
farther  in  Barker  and  other  advanced  cytologists,  enough  to 
entertain  your  leisure  hours  like  a  story  and  to  reveal  to 
you  how  much  stranger  than  literary  fiction  are  the  truths 
of  advancing  neurocytological  science. 

The  changes  other  than  chromatolithic  which  take  place 
in  the  neurone,  consist  of  varicose  hypertrophy  of  the  axone 
or  of  the  axis  cylinder  process  as  Golgi  described  it,  the 
granular  changes  of  Bevan  Lewis  from  which  Ford  Robert- 
son dissents,  nucleal  displacements,  total  or  partial  neurone 
obliteration  or  necrosis,  homogeneous  degeneration  and 
atrophy  and  other  changes  not  yet  designated  by  name  in 
cytology  and  other  transformations  of  cells  yet  to  be 
described.  These  will  add  to  the  marvels  of  your  micro- 
scopes, as  you  may  find  time  to  look  for  them  and  search 
out  the  mysteries  of  microcosm  for  yourselves. 

Lugaro's  more  recent  views  also  upon  the  pathological 
significance  of  lesions  of  the  chromatic  and  achromatic  parts 
of  cells  considered  of  so  much  interest  and  great  practical 
importance  that  he  quotes  as  follows,  which  1  give  you  as 
still  apropos  to  our  subject  and  in  proof,  from  higher  author- 
ity, of  what  1  have  already  said. 

"From  the  complex  of  the  studies  that  have  been  made 
we  may  also  form  criteria  of  the  reparability  of  the  lesions. 


11-' 

We  know  that  the  lesions  of  the  chromatic  part  of  the 
neurone  .  are  the  first  to  appear,  in  all  cases  in  which  the 
harmful  action  dues  not  act  suddenly  and  with  such  energy 
as  to  paralyze  function;  that  they  are  in  every  case  repar- 
able even  when  very  grave,  provided  that  ether  parts  of 
the  cell  have  not  suffered  serious  damage.  It  is  very 
doubtful  if  lesions  of  the  achromatic  parts  can  be  repaired, 
more  especially  since  they  very  often  appear  contempora- 
neously with  lesions  of  the  nucleus,  the  integrity  of  which  is 
indispensable  for  the  conservation  of  the  cell. 

Of  great  importance  is  the  question  if  functional  dis- 
turbances ought  tn  be  considered  as  an  expression,  pure  and 
simple  <>t  the  lesions  revealed  by  Nissl,  that  is  to  say,  of 
those  that  concern  the  chromatic  part  of  the  cell.  The 
results  of  experimental  researches  tell  us  clearly  that  an 
exact  and  constant  relation  there  is  not;  that  function  can 
be  disturbed  without  there  being  any  apparent  lesion  of  the 
chromatic  part,  which  on  the  other  hand  may  be  altered, 
even  gravely,  without  our  being  able  to  discover  any  evident 
functional  disturbance. 

In  acute  poisonings,  especially  by  substances  which 
exhibit  rapid  diffusion  and  action,  such  as  chloroform  and 
ether,  when  there  is  really  an  imposing  symptomatological 
picture,  or  when  the  toxic  action  has  already  determined 
death,  one  cannot  recognize  any  apparent  modifications  in 
the  chromatic  parts  of  the  nerve  cells.  Modifications  are, 
on  the  other  hand,  very  evident  in  sub- acute  poisonings, 
even  before  functional  disturbances  have  appeared. 

This  shows  without  doubt  that  the  functional  activity 
of  the  cell  can  continue  even  when  the  chromatic  part  is 
injured,  and  that  this  part  does  not  possess  structural 
arrangements  necessary  for  the  fulfillment  of  its  function, 
which    depends    therefore,  upon    chemical    composition,  and 


11  ! 

not  upon  morphological  disposition.  If  to  this  we  add  the 
fact  that  the  chromatic  part  is  rapidly  affected  every  time 
that  metabolism  is  disturbed,  locally  or  generally,  and  that 
it  diminishes  in  quantity  in  consequence  of  protracted  func- 
tional activity,  we  can  hardly  doubt  that  the  chromatic  part 
plays  a  very  important  role  in  the  functional  metabolism  of 
the  nervous  element,  and  that  therefore  its  alterations  are  a 
direct  index  of  nutritive  alteration.  In  other  words,  they 
are  not  exactly  proportional  to  the  functional  disturbance; 
within  certain  limits  of  structural  alteration  function  can 
remain  intact,  and  will  not  exhibit  disturbance  with  certainty 
except  in  cases  of  grave  alteration,  when  the  nutritive 
alteration  is  also  grave.  On  the  other  hand,  function  will 
be  entirely  suppressed  when  the  structural  dispositions  of 
the  achromatic  part,  which  seem  more  strictly  related  to  the 
nervous  conduction,  are  altered,  or  when  they  are  suddenly 
affected  by  energetic  chemical  action,  and  Ford  Robertson 
considers  it  also  very  probable,  that  purely  local  degenera- 
tive changes  in  the  branches  of  the  dendrites  and  in  the 
collaterals  of  the  axis-cylinder  processes  are  of  considerable 
importance  in  nerve  cell  pathology."  And  why  not?  For 
as  I  have  told  you  in  a  previous  lecture,  no  change  can 
take  place  in  structure  without  that  change  being  corre- 
spondingly felt  in  function  even  though  it  may  be  so  slight, 
like  the  ripple  of  a  pebble  dropped  into  the  ocean  at  night 
time,  as  not  to  be  revealed  to  our  vision.  The  chromatic 
part  of  the  cell  may  be  likened  in  its  relation  to  the  achro- 
matic portion  of  the  neurone,  to  the  porch  of  a  house.  The 
house  does  not  greatly  suffer  if  the  porch  gets  a  coat  of 
paint. 

The  neurones  and  all  the  nerve  elements  of  a  nerve 
center,  while  definitely  affecting  certain  nerve  centers  so  as 
to  attract  one's  special  attention  there  and  give  the    symp- 


114 

torn  grouping  especial  designation  of  a  particular  nervous 
disease,,  may  involve  other  centers — certain  systemic  diseases 
of  the  spinal  cord,  for  instance,  implicating  the  medulla 
oblongata  and  other  important  centers  without  its  being  the 
chief  location  of  the  disease  Take  for  illustration,  locomotor 
ataxia,  called  also  tabes  dorsalis  or  posterior  spinal  sclerosis, 
the  latter  to  designate  its  special  pathological  seat  in  the 
posterior  root  zones  of  the  spinal  cord.  Its  characteristic 
lancinating  pains,  which  show  sensory  disturbances  origina- 
ting in  the  posterior  column  and  the  later  trophic  changes 
in  the  joints  from  trophic  center  invasion  of  the  spinal  cord, 
are  not  all  of  the  symptoms,  though  they  prominently 
engage  our  attention.  In  this  disease  we  have  also  the 
implication  of  the  cilio- spinal  center,  high  up  in  the  cervical 
segments  of  the  cord,  giving  the  Argyll-Robertson  pupil, 
and  we  have  the  involvement  of  the  medulla  in  the 
laryngeal  and  pharyngeal  crises  and  even  the  implication  of 
the  fourth  ventricle  of  the  brain  as  shown  in  the  vagus 
disturbance  which  comes  on  later  in  the  disease,  contribu- 
ting to  cause  the  gastric  crisis,  as  it  is  called,  of  locomotor 
ataxia. 

Myelitis  or  inflammation  of  the  cord  may  also  involve 
the  medulla.  So  also  may  progressive  muscular  atrophy, 
amyotrophic  lateral  sclerosis,  multiple  or  disseminated  scle- 
rosis and  gliosis,  of  which  you  are  yet  to  learn  much.  These 
diseases  may  attack  this  vital  nerve  center  in  their  onward 
and    upward  progress. 

Reflex  functional  nervous  disease  is  also  of  the  nature 
of  extra -neural  or  adneural  disease,  as  when  an  intestinal 
irritation  excites  the  so-called  convulsive  or  spasm  centers 
of  the  medulla,  as  Nothnagle  designated  them,  since  contro- 
verted by  Oppenheim  and  others.  This  is  only  the  morbid 
touching   of    vasomotor    centers    whose    irritation    from    ec- 


115 

centric  or  peripheral  disturbance  impresses  the  blood  supply 
of  the  arterioles  or  nourishing  blood  vessels  of  the  psycho- 
motor or  other  areas  of  the  brain  and  medulla,  throwing  the 
brain  into  convulsive  states*  causes  fainting,,  nausea,  etc.  the 
nausea  itself  being  a  reflex  impression  back  to  the  stomach 
through  the  vagus  center  impression,  as  the  head  may  be 
affected  from  the  stomach,  the  condition  causing  nausea  by 
sending  its  impressions  up  through  the  vagi  or  paralyzing  the 
vaso-motor  centers  and  making  the  brain  hyperaemic  as  I  have 
seen  it  from  an  intestinal  tape  worm.  Disturbances  of  the 
brain  from  visual  defects  are  of  this  nature  and  from  sudden 
peripheral  injuries  such  as  cause  fainting,  nausea,  etc.,  by  its 
impression  up  through  the  pneumogastric. 

Extra- neural  states  affecting  the  nervous  system  in  one 
part  may  also  be  the  result  of  nerve  center  disorder  in 
another  as  when  the  heat  centers  are  so  deranged  that  the 
normal  balance  between  heat  production  and  heat  distribu- 
tion is  not  maintained  and  hypothermia  or  hyperthermia 
and  their  consequences  follow. 

A  good  deal  of  see-saw  reflex  impression  both  eccentric 
and  centric  takes  place  throughout  the  nervous  system  by 
means  of  its  wonderful  central  and  peripheral  connections,  as 
you  are  soon  to  discover,  as  we  proceed  in  our  elucidations 
of  neurology.  The  cerebro-spinal  and  sympathetic  neural 
chain  is  a  chain  of  many  marvelous  links  and  of  wondrous 
mechanism  as  you  will  learn  before  you  become  finished 
neurologists.  When  we  contemplate  its  "vast  chain  of 
being,"  "as  we  see  it  in  the  cerebro-spinal  axis  and  its 
allied  sympathetic  and  other  parts  of  the  peripheral  nervous 
system,  we  are  prompted, from  a  higher  possession  of  neural 

*"Bechterew,  who  confirmed  Nothnagle's  observations,  showed  that  these  spasms 
appearing  in  a  lesion  of  a  definite  pontine  area  (Vasomotor  centers?)  are  derived  from  the 
cerebrum." — Mayer's  Oppenheim,  1900,  p.  626. 


116 

knowledge  than  the  psalmist  to  exclaim,  "how  wonderfully 
wrought." 

Parasites  and  the  parasitic  growths  which  they  develop 
about  them  in  the  brain  or  elsewhere  in  the  nervous  system 
are  extra-neural  causes  of   nervous  disease  like  gliomata  in 

the  neuroglia  or  mesoglia  between  the  neurones.  Echino- 
cocci  and  cysticerci  are  the  chief  parasites,  and  they  usually 
attack  the  brain  surface,  causing  hydatid  cysts. 

Morbid  involvement  of  the  neuroglia  and  mesoglia  are 
in  the  nature  of  extra- neural  disease,  coming  under  the 
head  of  what  Lugaro  would  call  inter- neuronic  in  contra 
distinction  from  intra- neuronic  or  within  the  neurone  proper. 
A  distinction  has  also  been  made  between  disease  of  the 
cell  prolongation  and  of  the  cell  itself  by  this  author.  A 
physio- chemical  change  takes  place  in  an  efferent  nerve 
fiber,  which  causes  a  physio-chemical  change  in  its  neigh- 
boring neuroglia  and  adjoining  neurones,  which  may  be 
partly  inter-neural  and  partly  intra-neurai.  But  we  will 
not   further   discuss   this    subject    now. 


FIG.  51. 


it 


ii 


MJb 


>TvAYu.mewXs 


rectstorv 


otaectnx>raeA.e 


A,  spiral  surface  thermometer, 

B,  Seguin's  flattened  bulb  surface  thermometer. 

C,  Immisch's  watch-shaped  surface  thermometer. 

D,  ordinary  water  thermometer  for  bath. 

E,  Landon  Carter  Gray's  covered  surface  thermometer. 

F,  ordinary  self-regulating  clinical  thermometer. 


ELECTRICAL    APPLIANCES. 

Besides  its  use  in  testing  for  the  reaction  of  degeneration,  electricity 
is  employed  for  the  treatment,  regulation  and  control  of  arteriole  circulation, 
(irritating  or  paralyzing  the  vaso-motor  system),  restraining  or  stimulating 
circulation,  stimulating  the  function  of  the  heart  and  other  organs,  tranquil- 
izing  the  sensory  nervous  system  and  alleviating  pain,  (by  altering  the 
molecular  activities  and  transmissibility  of  sensory  nerves),  promoting 
nutrition,  destroying  germs  and  morbid  growths,  electro-massage,  curing 
paralysis  and  paresis,  improving  and  restoring  defective  or  lost  sight  (in 
Seelinblindheit  especially),  and  for  various  diagnostic  purposes,  the  latter 
including  the  use  of  the  x-ray  and  the  electric  lights  in  various  forms  of 
endoscopes,  of  which  the  polyscope  is  a  combination.  It  is  used  in  general 
as  well  as  neurological  specialties,  and  in  most  of  the  specialties  as  well. 
Special  appliances  for  its  application  are  brought  into  requisition  in  special 
electro-therapeutic  work,  as  in  electro-cautery,  electro-catophoresis,  etc. 


GALVANO-FARADIC  DRY   CELL   BATTERY. 


The  various  forms  of  batteries  and  electrical  machines  and-  special  ap- 
pliances may  be  seen  in  the  illustrated  catalogues  of  the  manufacturers. 


CHAPTER    XI. 

INSTRUMENTS   AND   PROCEDURES  OF  PRECISION   IN   DIAGNOSIS 
AND   PRACTICE. 


The  perceptive  powers  are  enhanced  by  methods  and 
instruments  of  precision  in  diagnosis  and  practice.  The 
sight  is  improved  by  lenses,  as  when  with  the  opthalmo- 
scope  we  search  the  inner  chambers  of  the  eye;  the  tactile 
sense  is  helped  by  the  probe,  and  our  estimate  of  sensation 
is  assisted  in  its  measurement  by  the  assthesiometer.  The 
dynamometer  helps  us  to  appreciate  the  patient's  grip  and 
other  muscular  power;  the  degree  of  heat,  though  it  may  be 
felt  and  approximately  estimated  by  applying  the  hand  is 
accurately  recorded  by  the  thermometer  and  the  calorimeter. 
The  patient's  power  of  heat  appreciation  is  shown  by  the 
thermoaesthesiometer  and  of  his  sensitiveness  to  weight  by 
the  baraesthesiometer.  The  perimeter  measures  the  range 
and  area  of  the  field  of  vision;  the  tuning  fork  and  the 
acoumeter  are  used  for  testing  the  sense  of  sound,  the  com- 
pass points,  blunt  and  sharp,  for  testing  anaesthesia,  hyper- 
esthesia, hyperalgesia  and  analgesia;  the  stethoscope  for 
ascertaining  arterial  and  thoracic  and  abdominal  sounds,  the 
ophthalmoscope,  the  endoscope  and  x-ray  for  seeing  into 
the  cavities  beyond  normal  vision,  and  surgical  sounds  and 
probes  for  feeling  beyond  normal  touch,  etc.  The  constant 
current  battery  is  used  for  testing  the  reaction  of  degener- 
ation, the   faradic    for    ascertaining    the    degree    of    normal 

[117] 


118 

muscular  reaction,  etc.,  in  practice.  All  of  these  and  other 
appliances  used  by  the  advanced  neurologist  in  his  practice 
will  now  be  shown  you,  and  briefly  described. 

The     thermometers,    general     clinical,    and     local     have 
already  been  shown  at  the  end  of  the  preceding  chapter. 

FIG.  52. 


For  sampling  muscular  tissue  for  microscopic  examination,  pseudohypertro- 
phic muscular  paralysis,  progressive  muscular  atrophy,  etc.  A  is  the  handle 
with  D,  the  blade,  all  ready  for  use;  E  is  a  sliding  receiving  cylinder  at- 
tached to  and  under  the  blade  ready  to  be  thrust  forward  to  catch  a  minute 
piece  of  flesh;  C  is  the  'slide  button  which  you  push  forward  when  ready  to 
secure  on  the  cylinder  the  piece  of  flesh;  D,  D,  shows  the  blade  closed 
and  ready  for  withdrawal. 

FIG.  53. 

\vxxc^«si»«v  &Vvo*\tv«  o\AvCe.-oo2vvo;A,  ^^  * 


Hammond  was  a  worker  in  his  day  and  wrought  well 
in  the  neurological  vineyard.  You  will  hear  more  of  him 
from  me  later.  Here  is  a  sample  of  his  diagnostic  work 
with  the  harpoon  of  Duchenne  or  Duchenne's  trocar,  as  he 


119 

called  it.   (See  Fig.  52).     The    cut    shows  a  sample    of    thi 
muscle  striae  or  what  is  left  of  them,  taken  from  the  low 
portion  of  the  tibialis  anticus  of  a  boy  in  an  advanced  stage 
of  organic  infantile   paralysis.     "The  transverse  striae  have 
nearly  disappeared,  but  globules  are  seen  in    large  numbers 
and  fat  corpuscles  are  also  abundant." 

But  there  is  not,  as  Duchenne  affirms  and  as  Ham- 
mond says,  this  degeneration  in  every  case.  In  two  cases 
which  had  lasted  over  four  years,  Hammond  "found  the 
structure  of  the  muscle  unchanged."  1  only  show  this  one 
of  the  seven  samples  given  by  Hammond  under  the  caption 
of  "infantile  spinal  paralysis"  to  illustrate  one  of  the  uses 
of  this  sometimes  useful  little  harpoon. 

It  is  especially  of  service  in  determining  a  doubtful  ques- 
tion concerning  progressive  muscular  atrophy  of  the  degen- 
erative type,  as  distinguished  from  simpler  myasthenic  forms 
of  muscular  wasting.  Hammond  also  in  this  country  first 
described  the  diagnostic  use  in  neurology  of  the  dynamograph 
in  the  Journal  of  Psychological  Medicine,  New  York, 
January,  1868. 

THE   DYNAMOMETER  AND   ITS   USES. 
FIG.  54. 


\A u vci  -XtXcuWv e\x  U  v^xvOvXuatn etc  r 

The    ordinary    dynamograph  (from    the     Greek   Sum/us, 
power    and  ypacfrav,  to    write,  is  a    dynamometer     with    an 


120 

attachment  for  automatically  registering  power.  In  this 
sense  the  instruments  of  Hamilton  and  Burq  are  dynamo- 
graphs  also,  for  they  automatically  register  strength,  but 
the  medical  dynamograph  makes  a  written  record  of 
muscular  power.  The  neurological  dynamograph  is  used 
for  recording  muscular  contractions,  and  is  also  of  value 
in  diagnosis.  The  neurological  dynamograph  is  made 
by  blending  the  features  of  a  Burq  dynamometer  with  those 
of  the  sphygmograph  for  recording  muscular  action.  It 
transcribes  to  paper  a  record  of  the  muscular  tonus  and 
power  of  the  individual  and  the  perfection  or  imperfection 
of  the  muscular  sense. 

The  use  of  this  combined  instrument  is  of  value  espe- 
cially for  record  of  cases.  But  sampling  the  patient's  hand- 
writing with  pen  and  pencil  and  requiring  him  to  make  straight 
and  curved  lines,  etc,  in  connection  with  the  dynamometer 
will  answer  most  purposes  of  this  feature  of  diagnosis, 
without  this  somewhat  expensive  instrument.  A  healthy 
person,  young  or  middle  aged,  makes  a  fairly  straight  line 
and  a  fairly  steady  signature.  Incoordination  modifies  pen 
or  pencil  strokes  or  signatures  and  senility,  nervous  debility, 
paralysis  agitans,  sclerosis,  chorea,  paralysis  or  insanity  are 
often  so  marked  by  changed  hand  writing  that  the  latter  is 
diagnostic,  so  that  the  pen  is  sometimes  as  mighty  as  the 
knife  in  diagnosis.  The  surgeon  sometimes  makes  explo- 
ratory incisions  for  a  purpose  similar  to  that  of  our  pen 
pictures  of  palsy  and  incoordination.  Our  records  are  blood- 
less.    Their  pathways  are  strewn  with  blood. 

The  best  of  all  hand  dynamometers  now  at  the  com- 
mand of  neurologists  is  the  excellent  rubber  bulb  upright 
one  devised  by  Dr.  Allen  McLane  Hamilton  of  New  York 
City.  It  does  not  hurt  a  tender  hand  like  the  Burq-Matthieu's 
and  does  not  require  in  its  use  such  an  extensive  grip  as  the 


121 


latter.  Its  only  disadvantage  is  that  the  rubber  after  a  time 
hardens  and  breaks,  but  the  springy  resistance  of  Matthieu's 
also  weakens  after  awhile  and  impairs  its  utility. 

THE  DYNAMOMETER. 
FIG.  55. 


T-n ' 


m 


One  of  the  most  valuable  instruments  in  neurological 
practice  for  testing  sensibility  is  the  assthesiometer  as 
devised  by  Sieveking,  and  one  of  the  most  important  dis- 
coveries in  neuro-diagnosis  was  that  of  Webber's  distance 
sensation  points. 

Here  is  an  illustration  of  an  assthesiometer,  devised  by 
myself: 

THE    AUTHOR'S    yESTHESIOMETER. 

FIG.   56. 

Three-fourths  Actual  Size  ('open). 


The  points  of  this  instrument  fold  up  like  a  pocketknife.  It  has  reversible 
sharp  and  blunt  points,  the  English  or  decimal  scale  and  Weber's  distance 
points  engraved  on  it.     It  is  constructed  of  aluminum  or  silver  and  steel. 


122 


FIG.   57. 


H.6.&M.I.C0. 


NK.POST 
Af?M 

BK 

LG" 
THl 


FT.DOR       I 
SAC        j 
PTA  .... 
V.F   NK.ANT. 
D.HD  .   .   .    . 


D  H.  MET.  -  • 
ZYG  .   .    ■    ■ 

6T.T0.PmcK 

N.D  32  F  ._ 
AlP  Z°FTIP~ 
F  TIP.  .  . 
T.TIP  .    •     •   . 


Exact  size  closed    tor    carrying    in  the  pocket. 
showing  the  distance  points  engraved  and  named. 


The  Eesthesiometer  was  invented  by 
Sieveking,  of  London,  in  1858.  E.  H. 
Weber  utilized  this  valuable  instrument 
in  the  making  of  an  important  discovery, 
namely,  that  the  power  to  recognize  two 
simultaneous  but  distant  impressions 
(cutaneous,  lingual,  etc.,)  varies  accord- 
ing to  the  distance  of  the  points  of 
contact  apart  from  each  other  in  differ- 
ent parts,  in  a  longitudinal  line  with 
the  body  in  health.  That  is,  there  is  a 
normal  variation  according  to  the  region 
tested.  There  is  also  a  comparative 
variation  or  departure  in  tactile  sensibility 
from  the  normal  perceptibility  of  the 
points  in  contact  with  the  body,  when 
nervous  disease  exists.  The  tongue, 
lips,  finger  tips,  back  and  palms  of  the 
^  hands,  wrists,  cheek,  chin,  dorsum, 
nucha,  middle  of  the  thigh,  etc.,  all 
have  physiological  distance  perception,  especially  in  line 
parallel    with    the    distribution    of   the    sensory  nerves. 

Any  departure  in  recognition  of  two  points  of  the 
ajsthesiometer  from  the  normal  distances  for  the  several 
localities,  indicates  disease,  anaesthesia,  hyperassthesia,  etc. 
In  the  most  sensitive  parts,  as  tip  of  the  tongue,  palmar 
surface  of  second  and  third  finger  and  red  surface  of  lips,  the 
points  are  distinguished  at  from  half  a  line  to  two  lines 
distant,  while  on  the  dorsum  of  the  tongue  and  back  or  an 


123 

inch  on  its  sides,  the  points  must  be  separated  four  lines 
or  more  to  be  perceived  in  health.  The  distance  is  a  line 
greater  for  the  dorsal  aspect  of  the  second  finger,  the  palm 
of  the  hand,  skin  of  the  cheek,  external  surface  of  the 
eyelids,  etc.,  while  the  normal  recognition  distance  widens 
at  the  zygoma  and  lower  forehead  to  ten,  at  the  lower  occi- 
put to  twelve  and  at  the  back  of  the  hand  to  fourteen  lines. 

The  vortex  and  upper  jaw  require  a  distance  of  fifteen 
lines.  The  normal  perception  distance  of  the  patella  is  six- 
teen lines,  that  of  the  sacrum,  accromion,  leg,  knee  and 
dorsum  of  foot  near  the  toes  is  eighteen  lines.  The  nerves 
of  the  skin  of  the  sternum  perceive  the  points  at  twenty 
lines.  Over  the  five  upper  cervical  vertebra?  and  the  spine 
under  the  occiput  and  in  the  loins  we  must  separate  our 
points  twenty-four  lines  distant  to  have  them  separately 
recognized  by  the  sensory  nervous  system  at  these  locali- 
ties of  the  back,  while  over  the  middle  of  the  neck  or  back, 
or  arm  or  thigh,  only  a  separation  of  the  assthesiometric 
points  to  thirty  lines  apart  will  elicit  distinctive  recognition. 
There  are  other  distance  points,  but  these  1  have  condensed 
from  Weber's  table  and  classified  them  so  that  you  may 
easily  remember  them. 

This  is  a  remarkable  property  of  the  sentient  nervous 
system.  1  suppose  if  we  could  get  at  the  fundus  of  the 
eye  we  should  find  it  so  sensitive  that  it  could  not  be  thus 
measured.  Sieveking's  aesthesiometer  consisted  in  adapt- 
ing to  a  graduated  measuring  bar  a  pair  of  sliding  points 
making  a  sort  of  beam  compass,  adapted  by  means  of  a 
graduated  curved  bar  to  a  pair  of  carpenter's  compasses 
and  Hammond  substituted  a  straight  measuring  bar. 

You  may  utilize  a  hairpin  and  any  measuring  scale 
that  shows  the  inch  divided  into  twelfths  or  decimals  for 
approximative  measurements.     Two  toothpicks  with  a  Web- 


124 

er's  table  and  measuring  scale  will  do,  but  for  absolute 
record,  accuracy  and  rapid  and  ready  use,  1  think  the 
instrument  1  show  you  of  my  own  devising  is  the  best  ex- 
tant. It  will  save  the  time  of  reference  to  Weber's  tables 
and  aid  your  memory  as  to  the  normal  distance  points. 


THE   BAR/ESTHESIOMETER,    PIEZOMETER,    ETC. 
FIG.  58. 

\LiTpoY,    a.  icxAKk^vv**. 


An  instrument  devised  by  Eulenburg  for  testing  the  sense  of  press- 
ure in  different  parts  of  the  body.    It  consists  of  a  button  at  the 
eud  of  a  spiral  spring  which,  as  it  is  pressed  upon,  turns  a  rer ' 
tering  needle  on  an  index.        .^  rt       -  .. 

The  distinguished  German  neurologist  Eulenburg, used  this 
little  device  for  testing  degrees  of  the  weight  sense  or  surface 
pressure  feeling.  Press  the  button  over  corresponding  spots 
on  opposite  sides  until  discomfort  is  complained  of,  then 
register  the  tender  or  painful  spot.  Practice  pressing  it  to 
the  skin  of  healthy  persons  and  the  neurotically  hyperass- 
thetic  and  note  the  difference.  It  will  also  register  degrees 
of  neuritic  and  other  forms  of  hyperesthesia.  Some  of  your 
patients  cannot  tolerate  the  static  electric  roller  applied  ever 
so  lightly  or  the  lightest  Franklinic  spark, because  of  extreme 
cutaneous  hyperesthesia.     Try  this  instrument  on  them  and 


125 

record  your  observations.  I  have  modified  the  dial  by  increas- 
ing in  number  the  index  spaces,  and  the  button  by  enlarging 
it  one-fourth  in  diameter.  It  has  been  of  some  service  to  me  in 
determining  a  degree  of  neuritis  associated  with  circumscribed 
meningitis  verticalli.  When  patients  come  to  you  revealing 
sense  disturbances  of  any  kind  on  their  cutaneous  surfaces 
as  heat  spots,  cold  spots,  circumscribed  assthesias  or  algesias 
(plus  or  minus)or  other  forms  of  sense  hallucination  like  for- 
mication, etc.,  classed  as  paresthesia,  it  would  be  well  to 
make  also  a  barassthesiometric  test  and  other  like  examin- 
ations to  find  out,  precisely  if  you  can,  the  exact  condition 
of  the  sensory  nervous  system  as  to  the  normal  or  abnormal 
manner  in  which  it  perceives  cutaneous  impressions. 

BEARD'S   PIEZOMETER. 
FIG.  59. 


Piezometer  (mefav,  to  press). 

Dr.  George  M.  Beard,  author  of  the  best-known  treatise 
extant  on  neurasthenia,  also  devised  an  ingenious  instru- 
ment for  testing  the  cutaneous  appreciation  of  pressure,  in 
examinations  of  the  sensory  nervous  system,  which  I  here 
show  you. 

The  ordinary  piezometer  is  used  for  testing  the  com- 
pressibility and  pressure  power  of  gases  and  liquids.  This 
instrument  consists  of  a  tube,  a  graduated  slot,  spring  and 
and  piston,  with  indicator  thereon  sliding  over  the  scale  on 
the  side  of  the  slot,  to  measure  the  sensitiveness  of  the 
skin  to  pressure.  It  shows  the  forehead,  cheeks,  finger 
tips  and    tongue  to  be    most    sensitive  to  pressure,  and  the 


126 

calves  of  the  legs,  dorsum  of  the  thighs  and  fleshiest  part 
over  the  flexor  muscle  group  of  the  forearm  to  be  the  least 
sensitive  to  pressure. 

rhe  sensory  nervous  system  is  one  of  the  vital  organ- 
isms ol  the  body,  a  part  of  its  most  important  physiological 
machinery.  It  has  important  centers  in  the  neuraxis  and  puts 
man  in  close  touch  with  all  parts  of  himself,  within  his  organ- 
ism, and  with  his  environments  without,  and  by  means  of 
gesthesiometry  we  are  brought  into  intelligent  touch  with  man 
in  disease.  For  instance,  the  girdle  and  lightning  pains  and 
paresthetic  sensations  of  posterior  spinal  sclerosis,  the  darting, 
painful  paroxysms  of  neuralgia,  the  throat  globus  of  hysteria 
and  the  aura  of  epilepsia.  These  are  all  aesthetic  perversions, 
revealed  through  disorder  involving  sensory  nerve  centers. 
Slight  appearing  conditions  of  the  sensory  nervous  system 
often  have  graver  significance  than  the  patients  attach  to 
them,  as  for  instance  the  paresthesias  (formications,  numb- 
nesses, tingling  sensations,  etc.)  which  precede  cerebral 
paralysis  and  the  graver  hallucinations  of  mania  a  potn  and 
delirium  tremens  or  epilesia.  On  the  other  hand,  patients 
sometimes  have  apprehensions  graver  than  the  fact  of 
nervous  disturbance  warrant,  but  these  are  usually  asso- 
ciated with  pain  disturbance,  though  often  underestimated. 
A  persistent  headache  may  presage  a  brain  tumor  or 
gumma,  a  grave  meningeal  disturbance;  or  an  evanescent 
headache  may  indicate  the  slight  meningeal  irritation  of 
transient  hyperemia  or  a  passing  toxaemia  as  after  an 
alcoholic    drunk;      "katzenjammer"  for    example. 

Marre's  and  Pond's  sphygmographs  for  recording  pulse 
and  Masso's  plethysmograph  and  balance,  devised  to  demon- 
strate changes  in  the  vascular  system,  are  likewise  useful  in 
neurodiagnosis.  Then  there  is  the  chronoscope  for  testing  or 
measuring  thought  reaction  time,  the  neuromobimeter  or  nerve 


127 

reply  measurer,  as  Dr.  Joseph  Warren  called  it;  also  the 
knee  reflex  measure  and  devices  that  readily  suggest  them- 
selves, as  salt,  sugar  and  pepper,  for  taste,  and  the  color- 
blind tests  of  ophthalmology. 

The  watch,  the  tuning  fork  and  Politzer's  acoumeter 
are  used  in  neurology  for  measuring  the  acuteness  or  dull- 
ness of  hearing  in  certain  suspected  brain  diseases  and 
for  topical  diagnosis  in  cerebrology.  By  them  we  may 
be  aided  in  locating  tumors  of  the  interior  of  the  brain, 
as  the  ophthalmoscope  also  aids  us  in  this  particular,  but 
not  so  much  as  the  eye  symptoms  independently  of  what 
the  ophthalmoscope  reveals. 

OPHTHALMOSCOPE,   NORMAL  AND  ABNORMAL 
EYE   FUNDUS. 

These  illustrations  show  for  comparison  the  normal 
and  abnormal  fundus  of  the  eye  and  the  instrument  by 
which  they  are  revealed. 

The  chief  value  of  the  ophthalmoscope  to  the  neurolo- 
gist is  in  the  determining  of  the  existence  of  optic  retinitis 
or  choked  disc,  evidencing  blood  pressure  or  altered  circu- 
lation in  the  brain  states  caused  by  tumors  gumma  within 
the  cerebrum  or  cerebellum. 

Optic  retinitis  is  associated  also  with  the  interstitial 
nephritis  of  morbus  Brightii,  which  very  often  is  a  sequen- 
tial condition  of  profound  brain  strain,  in  my  medical 
experience,  as  are  also  the  tube  casts  so  often  found  coex- 
isting with  the  albuminuria. 

A  good  deal  of  practice  will  be  necessary  before  you 
become  sufficiently  expert  to  use  the  ophthalmoscope  as  an 
instrument  of  diagnosis  of  intra-cranial  disease.  If  a  thor- 
oughly expert  ophthalmologist  is  convenient  to  you,  I  would 
advise    you    to  call    him    to  your    aid    where  the    nervous 


128 

symptoms  may  lead  you  to  suspect  a  cerebral  tumor  or 
other  serious  brain  disease,  or  when  you  have  that  nervous 
breakdown  which  precedes  and  goes  with  tube  casts  and 
albuminuria  and  where  you  likewise  should  look  for  con- 
joint and  confirmatory  optic  retinitis.  The  fundus  occult  is 
likely  to  befriend  you,  if  you  take  it  into  your  confidence 
in  the  diagnosis  of  these  grave  brain  nervous  system 
conditions. 

Our  lamented  colleagues,  Drs.  Murrell  and  Dickinson, 
in  the  chair  of  ophthalmology,  and  their  able  successor, 
Dr.  Henderson,  have  been  of  signal  help  to  us  in  this 
sphere  of  cooperative  neurodiagnosis,  as  have  Drs.  Green, 
Post,  Alt,  Saxl  and  others  of  this  city  and  elsewhere. 


LORING'S  OPHTHALMOSCOPE. 
FIG.  60. 


129 


NORMAL  EYE  FUNDUS. 
FIG.   61. 
a   v 


nasal 


"A 
sd  sa  n  se 


para* 


B 


—Head  of  the  Optic  Nerve. 

A,  Ophthalmoscopic  View.— Somewhat  to  the  inner  side  of  the  center  of  the  papilla  the  cen- 
tral artery  rises  from  below,  and  to  the  temporal  side  of  it  rises  the  central  vein.  At  the 
temporal  side  of  the  latter  lies  the  small  physiological  excavation  with  the  gray  stippling  of 
the  lamina  cribrosa.  The  papilla  is  encircled  by  the  light  scleral  ring,  (between  c  and  d),  and 
the  dark  chorioidal  ring  at  d. 

B.  Longitudinal  Section  through  the  Head  of  the  Optic  Nerve.  Magnified  14  x  1.— The 
trunk  of  the  nerve  up  to  the  lamina  cribrosa  has  a  dark  color  because  it  consists  of  medul- 
lated  nerve- fibers,  n,  which  have  been  stained  black  by  Weigert's  method.  The  clear  inter- 
spaces, se,  separating  them  correspond  to  the  septa  composed  of  connective  tissue.  The 
nerve-trunk  is  enveloped  by  the  sheath  of  pia  mater,  p,  the  arachnoid  sheath,  nr,  and  the 
sheath  of  dura  mater,  du.  There  is  a  free  interspace  remaining  between  the  sheaths,  con- 
sisting of  the  subdural  space,  sd,  and  the  subarachnoid  space,  sa.  Both  spaces  have  a  blind 
ending  in  the  sclera  at  e.  The  sheath  of  dura  mater  passes  into  the  external  layers,  sa.  of 
the  sclera,  the  sheath  of  pia  mater  into  the  internal  layers,  si,  which  latter  extend  as  the 
lamina  cribrosa  transversely  across  the  course  of  the  optic  nerve.  The  nerve  is  represented 
in  front  of  the  lamina  as  of  light  color,  because  here  it  consists  of  non-medullated  and 
hence  transparent  nerve-fibers.  The  optic  nerve  spreads  out  upon  the  retina,  r.  in  such  a 
way  that  in  its  center  there  is  produced  a  funnel-shaped  depression,  the  vascular  funnel,  b, 
on  whose  inner  wall  the  central  artery,  a,  and  the  central  vein,  v.  ascend.  The  chorioid..  d', 
shows  a  transverse  section  of  its  numerous  blood-vessels,  and  toward  the  retina  a  dark  line, 
the  pigment  epithelium ;  next  the  margin  of  the  foramen  for  the  optic  nerve  and  correspond- 
ing to  the  situation  of  the  chorioidal  ring,  the  chorioid  is  more  darkly  pigmented,  ci  is  a 
posterior  short  ciliary  artery  which  reaches  the  chorioid  through  the  sclera.  Between  the 
edge  of  the  chorioid;  d,  and  the  margin  of  the  head  of  the  optic  nerve,  c.  there  is  a  narrow 
interspace  in  which  the  sclera  lies  exposed,  and  which  corresponds  to  the  scleral  ring  visible 
with  the  ophthalmoscope.  ~  fo.^»fo*  $»&£) 


130  ABNORMAL   EVI£   FUNDUS 

Revealed  by  ophthalmoscopic  examination  in  cerebral  tumor  and  asso- 
ated  the  interstitial  nephritis  of  other  forms  of  disease  brain. 

FIGS.   62  AND  63. 


—Optic  Neuritis  (Choked  Disk).* 

A,  Ophthalmoscopic  View  of  the  Papilla.  Magnified  14  x  1.— The  papilla  appears  consid- 
erably  enlarged  and  without  distinct  outline.  It  is  of  a  grayish-white  color,  clouded,  and 
covered  with  radiating  striae  which  extend  into  the  adjoining  retina.  The  retinal  arteries, 
<t,  a.  are  contracted,  t  lie  retinal  veins,  v,  v,  are  exceedingly  dilated  and  tortuous,  and  both  are 
hazy  in  places.  Adjoining  the  papilla,  radially  disposed,  striate,  red  spots  (hemorrhages), 
h,  are  found  in  the  retina. 

2?,  Longitudinal  Section  through  the  Head  or  the  Optic  Nerve.— This  is  greatly  swollen, 
so  as  to  project  above  the  level  of  the  adjacent  retina  and  form  at  the  hase  an  annular  tume- 
faction, the  ueuritic  swelling,  n.  There  is  a  cellular  infiltration,  particularly  along:  the  mi- 
nuter blood-vessels,  e,  for  which  reason  the  latter  stand  out  with  a  special  prominence.  The 
retina,  r,  is  thrown  into  folds  about  the  circumference  of  the  papilla,  in  consequence  of  the 
swelling  of  the  latter  ;  the  chorioid.  ch,  and  the  sclera,  s,  are  normal,  as  is  the  optic  nerve 
posterior  to  the  lamina  crilirosa.  Here  there  simply  exists  a  dilatation  of  the  intervaginnl 
space,  i,  through  accumulation  of  fluid,  in  virtue  of  which  the  greatly  folded  arachnoid 
sheath,  ar,  is  especially  well  marked  ;  du,  dural  sheath  ;  p,  pial  sheathAvtfe*  ^atVxs) 


131 


FIG.  64. 

Ql'l   ■i.lniriii— ■— ^ 


A  cautery  is  an  apparatus  founded  on  the  property  possessed  by  plati- 
num, when  heated  red  hot,  of  remaining  incandescent  as  long  as  the  vapor 

of  a  hydro- carbon  is  projected  upon  it. 
A  hollow  piece  of  platinum,  varying 
in  shape  according  to  the  purpose  in 
view,  is  attached  to  a  tube  connected 
with  a  reservoir  of  benzin,  the  vapor  of 
which  is  pumped  into  the  hollow  of  the 
piece  of  platinum  (previously  heated  in 
the  flame  of  a  spirit  lamp)  by  means  of 
a  hand  bulb.  (Foster.)  Bruce  in  Eu- 
rope and  J.  J.  Putnam  in  this  country 
have  modified  this  into  a  gas  cautery. 
Pacquelin's  cautery  is  especially  used 
for  producing  counter  irritation  in  spinal 
cord  disease. 

If  gasoline  is  considered  objectionable  or  too  inconvenient  and  gas  is 
handy  the  gas  instrument  of  Dr.  J.  J.  Putnam,  of  Boston, is  an  improvement. 
But  the  Pacquelin  cautery  or  McLane  Hamilton's  substitute  for  it,  in  places 
where  gas  is  not  procurable,  are  our  main  reliance  for  thermo-cautery  in 
treatment  of  spinal  cord  disease.  Actual  cautery  is'  a  substttute  for  the 
moxa  and  blisters. 

Where  a  contrary  (cooling)  effect  over  the  vertebrae  or  cranium  is 
desired,  strong  chemically  pure  ether  lotions  or  sprays  may  be  employed, 
saturated  if  desired,  with  menthol. 


Stereognosis  is  the  ability  to  recognize  the  shape,  size 
and  other  properties  of  objects  through  the  sense  of  touch 
and  feeling  (o-re/aeos,  solid,  yvwwn  which  signifies  to  know). 
Asteriognosis  is  a  modification  of  the  tactile  sensibility  and  is 
especially  valuable  in  diagnosis  in  the  line  of  a  person's 
trained  knowledge  as  to  the  form,  size  and  weight  of  objects 
he  may  have  been  accustomed  to  daily  handling.  As  for 
instance,  a  grocer  with  scale  weights,  eggs,  potatoes,  a 
bank  paying  teller  with  bank  notes.  The  latter  would 
hardly  be  a  good  test  for  doctors. 

If  an  individual  cannot  recognize  the  form,  size  and 
weight  of  objects  with  which  he  is  especially  familiar  by 
daily  routine  practice,  (a  doctor  with  a  hypodermic  syringe  or 
a  surgeon  with    scalpel    or  needle),  for  example,  grave  an- 


132 

aesthetic  or  paresthetic  mischief  might  be  suspected  and  if 
he  called  them  something  very  foreign  to  their  real  nature, 
as  snakes,  lizards  or  other  reptiles  or  some  insect,  sensory 
delusion  pointing  to  cortex  lesion  would  probably  be  present. 

The  hsemoglobinomeler,  the  urinometer,  the  microscope, 
the  test  tube,  the  endoscope,  the  pleximeter,  the  stetho- 
scope, the  atoscope,  the  laryngoscope  and  other  cavity 
speculi,  etc.,  are  all  of  use  in  diagnostic  neurology,  as  they 
are  in  other  departments  of  diagnostic  medicine,  but  as  they 
are  shown  by  the  other  chairs  we  need  not  specially  de- 
scribe them.  For  diagnosis  by  exclusion  the  neurologist 
must  sometimes  use  the  surgeon's  sound  aspirator  and 
probe  and,  even  sometimes  he  may  have  to  call  in  the 
surgeon  to  make  exploratory  incisions,  and  the  surgeon 
would  likewise  do  better  in  diasnosis  than  he  sometimes 
does  in  conditions  connected  with  nervous  women  if  he 
would  also  oftener  summon  the  neurologist  to  aid  him 
in  some  directions  in  diagnosis  connected  with  these  uncer- 
tain creatures  with  uncertain  diseases.  But  mutual  diag- 
nostic aid  in  these  matters  is  gradually  coming  about  with 
the  most  intelligent  practitioners  as  knowledge  broadens 
and  our  great  science  advances  in  its  power  of  exactly  de- 
tecting morbid  conditions. 

CEREBRAL  TOPOGRAPHY  CASTS. 

Casts  are  used  in  neurology  for  refreshing  and  increas- 
ing our  knowledge  of  surface  regional  brain  anatomy,  es- 
pecially in  making  out  cerebral  localizations.  Casts  like 
those  of  His  are  also  of  great  value  in  the  study  of  em- 
bryology, as  are  also  the  wax  figures  of  the  nervous  sys- 
tem and  atlases  like  Flowers'  and  others,  to  hang  on  your 
office  walls  and  keep  the  anatomy  of  the  nervous  system 
ever -before  you,  and  thus  prevent  it  from  fading  from  your 
memory. 


133 


CEREBRAL    TOPOGRAPHY. 
FIG.   65. 


nlerpuridal  fissure. l/-:VI / __  7_ 


occipitotemporal 


externa!  part  of 
middle  frontal 
convolution. 

Sylvian  fissure. 

parallel  fissure  or  first 
temporo-splitnoi'Jat 


FIG.  66. 
iWfrcssek's  Knee-jerk  Reinforcement  JTldWt 


FIG.  67. 

Method  of  apply- 
ingthe  dynamometer 
to  the  foot. 


134 


FIG    68. 


FIG     69. 


FIG.    70. 


FIG.   71. 


Tlie  tips  of  tlie  fingers,  or  sides  of  the  open  hand,  or 
a  narrow  book  or  ferrule  may  be  used,  in  lieu  of  a 
pleximeter,  for  eliciting  the  knee-jerk  and  other  reflexes. 
You  yet  the  ankle  clonus  better  by  grasping  the  foot  nearer 
the  ends  of  the  toes  than  is  illustrated  in  the  cut  and  by 
resting  the  calf  more  lightly  on  the  other  hand  than  is 
shown  in  the  illustration.  The  Jendressek  reinforcement  is 
further  reinforced  by  having  the  patient  shut  his  eyes  and 
by  placing  him  on  an  uncovered  table  that  has  no  slanting 
cushion  or  padding  of  any  kind  on  it  and  by  having  the 
patient  incline  his  body  forward  with  the  eyes  shut  as  you 
make  the  knee  tap. 


135 


FIG.  72. 


CYSTOSCOPE,  n.  Lajt.,  cjialosr.opium  (from  *v'u- 

tic,  the  bladder,  and  anontiv,  uj  examine).  Fr..  c.  Ger'.,  Cyttoskop.' 
An  Instrument  fur  the  ocular  examination  of  the  interior  of  the 
urinary  bladder.    Nitze's  C.  consists  of  a  closed  tube  with  windows 


Wall  of  the  bladder. 


Platinum.  ' 

Prism. 


v 

Telescope. 


Telescope. 


Wall  of  the  bladder. 


Water-pipes 


Water-pipes. 


NITZE'S  CYST08COPE.      (AFTER  W.  MEYER.) 

FatTtds  DlZTH>M/i$y 
through  which  a  pencil  of  light  from  a  loop  of  platinum- wire  ren- 
dered incandescent  by  a  galvanic  current  may  be  thrown  by  the 
aid  of  a  prism,  and  through  which  the  observer  views  the  vesical 
mucous,  membrane,  the  whole  being  surrounded  by  a  larger  tube 
through  which  cold  water  is  kept  flowing.  [W.  Meyer,  "  N.  Y.  Med. 
Jour.,"  Apr. .2JL1888,  p.  426.] 


You  do  not  need  to  become  as  expert  as  my  friend  and 
former  pupil,  Professor  James  P.  Tuttle,  now  of  New  York, 
in  the  use  of  the  cystoscope,  for  its  use  belongs  to  his 
daily,  even  hourly,  business,  but  you  should  know  enough 
about  what  it  may  reveal,  to  be  able  to  diagnosticate  by 
exclusion  a  neurotic  from  an  organic  disease  of  the  bladder. 

There  are  various  modifications  of  this  form  of  endo- 
scope, one  excellent  one  by  Dr.  Bransford  Lewis,  of  this 
city.  But  1  need  not  go  further  in  the  description  of  this 
instrument  of  precision  in  diagnosis,  as  it  is  not  used 
chiefly  for  neuro-diagnosis,  except  as  I  have  said  for  the 
excluding  of  the  possibility  of  organic  bladder  disease  or 
of  finding  it  associated  with  nervous  disease,  as  it  and  the 
whole  genito-urinary  system  are  sometimes  associated  with 
extreme    genital    hyperaesthesia,  making    life    miserable  and 


136 


even  beyond  the  resources  of  our  ordinarily  exceedingly 
resourceful  coadjutors,  in  practice,  the  genito-urinary  special- 
ists. My  genito-urinary  colleague  Dr.  Boogher  may  en- 
lighten you  further  on  this  subject.  Dr.  Phillips  is  also 
au  fait  in  this  business,  and  so  is  Bryson.  They  all  come 
to  our  aid  sometimes  in  confirmatory  diagnosis. 

FIG.   73. 


The  perforated  holes  in  the  straps  are  for  receiving  the  Seguin  surface 
thermometer  when  head  heat  measurements  are  being  taken. 

The  uses  of  this  adjunct  to  cerebral  thermometry  sug- 
gest themselves.  These  straps  should  have  been  shown 
you  when  we  were  on  the  subject  of  cerebral  thermometry. 

PERIMETER    AND    VISION    FIELDS. 
FIG.  74. 


-Schwcicccr't  perimeter. 


A  perimeter  is  an    instrument   for  finding   and   mapping 
out  the  vision  fields. 


137 


-Normal  field  Division .    . 

Fields  of  vision  recorded  by  the  perimeter  are  called 
perimetric  field  charts,  but  the  vision  field  is  not  called  the 
perimetrium.  The  perimetrium  has  an  entirely  different 
meaning.     It  means  the  peritoneal  covering  of  the  womb. 

fig.  76. 


f^lQlijgS' 


QwCjOvfte  of  (Xcto'o^eaQ.W-^ooolj  'Pa&ko.Tc&Af  (ie.  ScV 
FIG.    77 


-Field  of  Vision  of  the  Left  and  Right  Eve.     (After  Forster.) 


CHAPTHR  XII. 

INSTRUMENTS  OF    PRECISION  (CONTINUED). 


WILSON'S  CYRTOMETER  perforated  with  holes  and 
the  stem  of  a  Seguin  surface  thermometer  passed  through 
them  to  its  broad  expansion  and  the  latter  applied  next  to 
the  skin  might  be  substituted  in  head  heat  testing  for 
Carter  Gray's  thermometer  straps.  It  could  be  thus  used 
to  serve  the  double  purpose  of  locating  cerebral  motor 
centers  and  excessive  heat  spots  in  the  brain. 

Wilson's  Cyrtometer  was  first  described  in  the  London 

Lancet  in   1888  by  A.  W.  Hare  March  3rd,  page  407,  and    is 

fully    illustrated     and    defined  in    Foster's    dictionary.     The 

name  is  formed    from    the  Greek    ki'/otos,  signifying    convex 

and     /xeVpov  a    measure,    meaning    a    device    for    measuring 

curves.     Callipers    come    under  this    definition  and    can  be 

used  for  measuring  the  curved  surfaces. of  the  cranium   and 

for  locating  the  psychomotor  centers  of  the  brain.     But  this 

device  of  Wilson's  is  a  special  one  for  readily    locating  the 

fissure  of  Sylvius  and  approximating  the  fissure  of    Rolando 

and  the  centers  grouped    about  the  Rolandic  area  or    motor 

center    area    of  the    cerebrum.     Cyrlomelrnm    is  the    Latin 

term,  the    French    use  the    same    term,  but    the    Germans 

have  a  less   euphonious    sounding   expression    for  it.     They 

call  it  Wolbungomesser,  which    means  better  than  it    sounds 

to  American  ears.     It  signifies    a  knife  to  cut    curves  with. 

But  you  must    "get  onto  the  German  curves"  of  language 

to  appreciate  terms  like  these. 

[138] 


1  V) 


THE  CYRTOMETER. 

FIG.   78. 


■WILSON'8   CYRTOMETER.      (ASTER   JURE,  I.  C.) 


FIG.   79. 


WILSON'S  CYKTOMETER  APPLIED. 
(AFTER  HARE,  I.  C) 


The  broadest  transverse  strip  of  the  cyrtometer  passes 
coronally  round  the  forehead,  corresponding  with  the  gla- 
bella or  hairless  space  between  the  eyebrows,  as  its  origin, 
(glabellas,  implying  hairless,) and  the  external  angular  process. 
The  narrower  longitudinal  strip  passes  backward  from  the 
glabella  in  the  middle  line  to  the  occiput.  This  strip  is 
marked  with  two  scales  of    letters;  capitals  in  its    posterior 


140 

fourth,  and  small  letters  about  the  middle  of  the  strip. 
These  two  scales  bear  an  exact  relation  to  each  other, 
calculated  to  suit  in  the  application  of  the  instrument  to 
the  ordinary  head.  Measured  from  the  glabella  backward 
to  any  given  small  letter  is  55.7  per  cent  of  the  distance 
from  the  glabella  to  the  corresponding  capital  letter;  thus, 
when  any  capital  letter  falls  directly  over  the  inion  (rnov, 
back  of  the  head  or  external  occipital  protuberance),  the 
corresponding  small  letter  will  coincide  with  the  top  of  the 
fissure.  A  third  narrow  reversible  strip  slides  on  the  lon- 
gitudinal strip  of  the  metal,  marking  an  angle  of  61°  open- 
ing forward,  and  marked  at  3;,4  inches  from  ils  attached 
end,  thus  giving  the  length  and  direction  of  the  fissure  on 
the  surface  of  the  head. 

CRUSE'S  DIABETOMETER  is  a  half  shade  polariscope 
showing  one  gramme  of  sugar  to  the  litre  of  urine.  It  is 
an  instrument  whose  use,  like  that  of  the  test  tubes  and 
modern  sugar  test  papers,  comes  within  the  scope  of 
neurological  practice  and  diagnosis.  It  is  important  to 
know  whether  or  not  there  is  sugar  in  the  urine.  For 
besides  the  intimate  association  of  diabetes  with  coma 
and  comatose  states,  with  diabetic  melancholia  and  hypo- 
chondriasis, various  other  nerve  center  states  engender  or 
are  associated  with  diabetes.  It  appears  often  in  connection 
with  giantism  and  acromegally.  The  sugar  test  of  the 
urine,  its  presence,  its  absence  and  its  recurrence,  like  that 
of  albumen  in  the  progress  of  certain  neuropathic  conditions 
of  the  central  nervous  system,  may  enlighten  you  as  to  the 
progress,  upward  or  downward,  a  case  may  be  making.  Look 
for  its  presence  in  the  urine  in  all  cases  of  profound  nerve 
center  shock,  especially  in  the  great  psychic  shock  of  an 
overwhelming  business  reverse  or  of  an  overmastering  sor- 
row, after  a  severe  and  prolonged  strain    of  vigilance,  or  of 


141 

business  or  great  loss  of  sleep,  terminating  in  profound 
depression  of  spirits  that  will  not  be  eased  or  comforted. 
And  you  will  sometimes  find  it  where  the  books  do  not 
direct  you  to  look  for  saccharine  urine.  Melancholia  and 
diabetes  melliius  or  glycosuria  are  often  found  intimately 
associated  as  I  have  said.  Profound  nervous  exhaustion  may 
engender  both.  Thinking  as  a  neurologist  1  would  designate 
the  associated  urinary  phenomenon  as  nerve  depression 
or  psycho-neural  diabetes,  but  it  is  often  called  diabetic 
melancholia,  putting  the  cart  before  the  horse  or  the  liver 
before  the  fourth  ventricle  and  associated  nervous  system 
as  being  concerned  in  the  morbid  metabolisms  that  permit  an 
excess  of  sugar  to  form  and  get  into  the  blood  and  out 
through  Ihe  kidneys.  You  may  put  the  hepatic  cart 
(  glycoglnic  liver  )  before  the  neurologic  horse  if  you 
want  to,  but  remember  the  fact  of  the  frequent  association 
of  profound  cerebro-psychic  depression  and  sugar  in  the 
urine  and  look  for  the  latter  and  remedy  it,  not  only  by  diet 
but  by  brain  rest  and  a  new  exhilarating,  diverting,  restful 
psychic  and  better  physical  environment  for  your  patient. 
Codiae,  mix  vomica,  chloral,  laxatives,  good  nutrition  and 
haspatic  and  systemic  tonics  will  help  also. 

The  essential  pathology  of  mellituria  or  diabetes  has 
not  been  located.  It  is  not  in  my  judgment  primarily  in 
the  liver.  It  is  not  in  the  kidneys.  The  sugar  accumu- 
lates in  the  blood  and  is  called  glycohsemia.  Some  altera- 
tion has  taken  place  in  the  metabolic  processes  and 
glycohasmia  and  glycosuria  are  the  results.  Behind  there 
are  nerve  center  changes  which  have  not  yet  been  cer- 
tainly located  to  the  satisfaction  of  pathologists.  Having 
seen  glycosuria  come  and  go  in  the  course  of  grave  nervous 
depression  and  keeping  in  mind  the  fact  that  irritation  of 
the  floor  of    the    fourth  ventricle    develops  it  in    animals,  I 


14.' 

look  upon  diabetes  mellitus  revealing  glycohaemia  con- 
sidering the  many  melancholiacs  in  whom  1  have  seen  it 
appear,  as  a  brain  strain  sequence  in  many  if  not  all 
instances.  The  amount  of  glucose  in  the  urine  may  reach 
from  eight  to  ten  per  cent  in  grave  cases.  And  such  grave 
cases  usually  become  chronic  and  fatal,  though  1  have  had 
an  occasional  recovery  where  the  saccharine  polyuria  was 
excessive  and  the  melancholia  profound. 

When  the  water  dribbles  from  your  patient's  bladder 
or  passes  involuntarily  in  larger  quantities,  or  passes  vol- 
untarily too  often  or  will  not  pass  at  all,  or  passes  during 
sleep,  (eneuresis)  or  if  a  constant  desire  to  micturate  exists, 
it  is  important  for  you  to  be  assured  that  no  organic  con- 
dition exists  to  cause  the  trouble.  A  belladonna  or  opium 
anointed  catheter  with  bromide  of  potassium  and  acetate  of 
potash,  etc.,  internally,  will  help  these  conditions  if  only 
neural  hyperesthesia  and  a  heavy  irritating  urine  are  the 
causes.  But  the  cystoscope  will  aid  you  in  assuring  your- 
selves whether  the  fault  is  only  in  the  bladder.  A  cyto- 
scope will  help  you  in  neurology  as  well  as  in  general 
medicine  and  surgery.  Accustom  yourselves  to  see  as  far 
into  and  through  your  patients  as  you  can  and  you  will 
escape  the  reproach  and  help  to  spare  the  profession  one 
of  its  chief  reproaches,  namely,  that  of  inadequate  and 
complete  diagnosis.  They  are  made  in  neurology  as  well 
as    elsewhere. 

THE  DETECTION   OF  ABNORMAL  SENSATION. 

Hallucinations  are  false  perceptions  of  sensation.  The 
hallucinations  of  the  special  senses  of  sight,  hearing  and 
smell,  connected  with  disease  of  their  special  sense  centers, 
as  in  epilepsy  and  certain  forms  of  insanity,  have  been 
well  studied,  as  well  as  the   special    nerve  center  and  per- 


143 

iphery  changes  that  lead  to  real  disorders  of  sight  and  taste 
and  hearing.  Disorders  of  the  general  sensory  nervou 
system,  too,  as  I  have  told  you  in  a  preceding  lecture,  have 
received  some  consideration,  giving  us  the  anaesthesias, 
hyperesthesias,  paresthesias,  etc.,  recorded  in  the  literature 
of  neurology.  But  exact  measurements  of  these  abnormal 
impressions  or  false  .sensations,  that  is,  methods  for  detect- 
ing whether  they  are  real  or  not,  whether  they  have  a  local 
cause  or  result  from  sensation  disturbing  disease  in  or  near 
the  centers  of  sensation  in  the  brain,  have  not  been  so 
well  studied.  Disease  in  the  lower  part  of  the  corpus 
striatum,  one  of  the  basal  ganglia,  may  cause  alterations  in 
peripheral  sensation.     Spinal  cord  center  disease  likewise. 

In  psychiatry  which  is  the  study  of  mental  aberrations t 
great  pains  are  taken  by  men  who  aim  to  be  certain  and  val- 
uable in  their  opinions,  (and  all  should  so  endeavor  in  so 
important  a  matter),  to  be  sure  that  the  apparent  delusion 
is  not  really  a  fact  of  the  body  and  not  a  fancy  of  the 
mind;  though  delusion  is,  however,  an  impression  on  the 
gray  cortex  of  the  brain  deceiving  the  mind.  If  a  patient 
has  formication  and  slaps  himself  and  you  find  on  examin- 
ation that  his  bed  or  body  is  really  full  of  bugs  which 
disappear  when  lights  are  lit,  he  is  not  "buggy"  in  the 
slang  sense  of  that  abominably  vulgar  synonym  for  insanity, 
but  he  is  really  and  truly  buggy,  and  the  remedy  consists 
in  treating  the  bugs  and  not  the  patient.  So  too,  a  patient 
may  imagine  pediculae  and  have  them  on  his  person  or 
may  have  lately  had  them  and  the  mental  impression  still 
abides  as  it  will  sometimes  for  several  days  after.  The 
first  impression  would  be  no  delusion.  The  second  would 
be  an  illusion  persisting  after  the  exciting  cause  is  removed. 

Do  you  remember  the  first  time  your  good,  tender, 
patient,  loving,  anxious    mother   found    the    hirsute  of    your 


144 

caput  in  the  possession  of  a  tribe  of  pediculi  and  went 
through  your  hair  with  a  line-toothed  comb,  how  you  felt 
for  several  days  after  the  enemy  was  cleared  from  the 
field  as  if  they  were  still  there,  though  you  had  faith 
in  your  mother  and  knew  she  would  never  let  an  enemy 
to  your  peace  and  comfort  and  rest  and  happiness  of  that 
kind  escape  her  comb  while  she  had  breath  and  power  to 
wield  it?  The  first  sensation  was  the  real  thing.  You 
had  them.  The  second  was  an  illusory  impression.  Some- 
thing had  been  there  to  excite  the  impression.  You  believed 
they  were  still  there  but  actually  they  were  not.  That 
was  a  delusion  pure  and  simple.  You  got  them  from  the 
boy  you  had  the  scrimmage  with.  That  was  no  delusion. 
You  thought  you  got  the  better  of  him.  That  was  a  delu- 
sion, for  though  he  got  the  licking  you  got  the  pediculae. 
The  scratch  was  on  you.  Such  is  life  in  our  boyhood 
days.  It  has  its  illusions,  hallucinations,  delusions,  even 
rationally  founded,  as  later  periods  of  life  have.  Later  in 
the  session  I  will  tell  you  what  morbid  cortex  hallucinations, 
illusions  and  delusions  are  and  how  we  may  distinguish  them 
from  deceptions  that  are  rationally  and  healthily  founded. 
The  subject  is  a  moving  and  timely  theme  for  profitable 
discourse,  and  irrational  delusion  must  be  rationally  studied 
by  the  physician. 

It  is  well  to  test  the  discriminating  sense  or  power  of 
perception  of  the  sentient  nervous  system  in  various  ways. 
For  while  the  sensory  nervous  system,  when  it  or  its  cen- 
ters are  diseased,  reveals  hallucinations  of  insects  or  snakes 
creeping  over  it,  or  of  water  being  poured  over  it  or  upon 
it,  or  hot  or  cold  air  being  blown  upon  it,  scalding, burning, 
freezing  sensations,  when  surrounding  temperature  does  not 
account  for  these  feelings,  the  absence  of  power  to  detect 
real  impresssion  of    this  sort    sometimes  exists    in    varying 


145 

states  of  anaesthesia.  You  may  try  artificial  formication; 
draw  hairs  or  fine  wires  or  strands  of  silk  over  the  cuta- 
neous surface  to  ascertain  if  the  sensory  nerve  endings 
properly  recognize  them  and  the  peripheral  nerves  transmit 
the  right  impressions  of  their  presence  on  the  surface  to 
the  brain.  This  will  help  you  in  diagnosis  of  nervous 
disease. 

fig.  80. 


23 


22 


21 


20 


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2  o 

3  o 

4  O 

5  O 
6Q 


AMERICAN     SCALE. 


GakWTer  GuoUj>eQV  Pu,p\loinN&e.TC- 


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8  9        10        11        12        13        14        15 


/O  ^Co  /■$"  WV^x'teJCvc   ^v»,£V\,   Ct*V<3p  lao-ij  ;  ^'CVojC'voxrv^ 


A  pupilometer  will  aid  you  in  measuring  the  size  of 
the  pupil,  and  in  estimation  of  its  variations  from  the  nor- 
mal in  form.  For  this  purpose  a  catheter  graduate  card 
or  scale  will  answer  every  purpose,  though  some  neurolo- 
gists use  a  special  device  like  the  one  1  show  you. 

The  pupil  dilates  after  division  of  the  motor  oculi  nerve, 
contracts  after  division  of  the  cervical  sympathetic  and  from 
disease  affecting  the  centers  whence  these  nerves  arise  and 
proceed  to  the  pupil  from  brain  or  cord.  The  pupil  is  also 
altered  in  size  and  shape  by  disease  involving  the  sight 
areas  of  the  brain,  the  optic  tracts,  the  cilio-spinal    center. 


146 

Disease  implicating  the  iris,  like  iritis,  the  lens,  like  cata- 
ract, the  chambers  like  glaucoma  or  the  retina  like  paraly- 
sis and  amaurosis,  change  the  appearance  of  the  pupil.  So 
that  here,  as  elsewhere  in  neurology,  your  diagnosis  must 
be  differentiated. 

The  Rhomberg  symptom  of  swaying  forward  and 
from  side  to  side  when  standing  with  the  feet  together 
and  the  eyes  shut,  one  of  the  locomotor  ataxia  signs,  may 
be  measured  by  a  light  bar  attached  across  the  head, 
and  so  arranged  as  to  slide  over  a  scale  frame  like  the  one  I 
show  you  or  by  the  ataxagraph,  a  cut  of  which  you  may 
see  in  Dana's  invaluable  neurological  text-book.  Exact 
measurement  of  this  sign  is  not  very  essential,  except 
perhaps,  for  record  in  certain  cases  and  for  comparison. 
Still  it  is  well  to  have  some  means  of  exact  record  and 
comparison. 

THE   MUTAMETER,   MOVEOMETER  OR  AMEBIMETER; 
A  MOVEMENT  RECORDER. 

Two  adjustable  bars  wide  enough  apart  to  permit  the 
head  to  rest  and  sway  some  between  them  are  secured 
across  a  hoop.  On  these  bars  are  secured  carpenter's 
scales.  A  band  is  adjusted  to  the  head  with  front  and 
lateral  roller  secured  to  them  firmly  and  resting  on  the 
bars.  The  degree  of  to  and  fro  and  side  to  side  tremor  is 
shown  in  the  movement  record  on  the  scale.  An  arm  from 
the  top  band  on  the  head  with  a  pencil  attachment  makes 
a  movement  record  of  the  tremor  also  on  card-board 
between  the  bars  and  the  hoop  walls.  This  instrument 
may  be  adjusted  to  the  feet  also  to  guage  impulse,  knee- 
jerk  and  heart  foot  tremor. 

You  may  construct  a  moveometer  out  of  a  cyrtometer 
and  a  scale  graded  frame  by  attaching  square    cork    blocks 


147 


to  the  sides  of  the  fronto-occipital  band  or  the  glabello- 
inion  band,  as  it  is  more  technically  called.  These  blocks 
slide  to  and  fro  and  from  side  to  side  on  the  scale  bars 
and  the  range  of  tremor  or  swaying  movement  of  dissemi- 
nated and  posterior  spinal  sclerosis'  are  thus  shown. 

FIG.    81. 


srder 


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r.i.,  M«W,..wl,   FFJ<«^».»^a-lI>..wA.G.GG.G.a«. 

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<Xoo.*.J  a.cros6  <0^  c?  (^^  co-^acXe.4   oX  eo.<V   &\i-e  WW 


CHAPTER    XIII. 

INSTRUMENTS   OF   PRECISION  (CONTINUED). 
THESPHYGMOGRAPH,  THE  PERCI'TEUR  and  the  polygraph  in  practice 

Each  left  ventricular  contracture,  or  systole  as  it  is 
technically  called,  of  the  heart,  sends  a  wave  of  blood  to 
and  onward  from  the  aorta,  causing  a  raised  arterial  ten- 
sion extending  on  to  the  capillaries.  This  pulse  wave  is 
measured,  in  medical  practice  usually  at  the  wrist  over  the 
radial  artery,  either  by  finger  or  instrumental  touch.  It 
may  be  measured  wherever  the  artery  is  sufficiently  super- 
ficial to  touch  with  the  finger  or  permit  the  adjustment  of 
an  instrument  to  it.  The  velocity  of  the  wave  pulse  varies 
from  four  (4)  to  twelve  (12)  meters  per  second  and  its  force 
varies  from  four  ounces  to  one  pound  or  more.  Richerand, 
the  old  French  physiologist  first  measured  the  force  of  the 
heart's  lifting  power  by  adjusting  weights  to  the  foot  of 
one  leg  crossed  over  the  other  at  the  knee. 

The  proper  term  for  a  pulse  measurer  is  pulsometer  or 
pulsimeter,  but  these  terms  have  been  appropriated  in 
mechanics  and  as  medical  science  needed  also  the  use  of  a 
combined  recording  and  descriptive  instrument,  Marie 
invented  the  pulse  measure  which  he  called  the  sphygmo- 
graph.  A  sphygmograph  therefore  is  a  recording  pulsometer 
the  motor  force  of  whose  mechanism  for  all  devices  up  to 
the  present  date  is  the  pulse  or  circulation  impulses  of  the 
artery  to  which  the  instrument  is  attached,  the  fundamental 

[148] 


149 

or  primary  pulse  resulting  from  the  primary  ventricular 
contraction  impulse  causing  the  initial  movement  stroke  of 
the  pulse  curve,  aided  by  clockwork  adjustment.  The  sec- 
ondary pulse  wave  follows  the  primary  curve  and  is  due  to 
the  elastic  nature  of  the  arterial  walls.  It  is  indicated  by 
a  secondary  elevation  following  the  initial  upward  stroke  of 
the  pulse  curve  as  the  lines  on  the  sphygmogram  show. 

FIG.   82. 

JL/7€  JjllKjaeon.   ^p/iy<ft?iocfTcup/i-' 


J       it 


The  term  sphygmograph,  (from  the  Greek  o-^vy/Ao?,  the 
pulse,  and  ypdv4>€tvt  to  write,)  is  an  apparatus,  as  you  are 
now  prepared  to  understand,  designed  for  measuring  and 
recording  the  blood  pressure  in  the  arteries  and  the  varia- 
tions in  the  heart's  beats  as  shown  by  the  pulse.  It  usu- 
ally consists  of  a  lever  or  a  system  of  levers  placed  upon 
the  arteries  and  connecting  with  a  registering  apparatus. 
Its  value  in  diagnosis    depends    on  the    fact    that  the  heart 


150 

and  pulse  beat  are  usually  synchronous.  Sometimes  the 
heart's'  beats  and  pulse  beats  are  not  synchronous — they 
are  asynchronous  and  this  is  not  a  good  omen  in  diagnosis. 

The  cardigrahh  measures  the  heart  beats  and  the 
yolygraph  combines  the  features  of  the  cardigraph,  sphy- 
gmograph,  etc. 

The  sphygmogram  is  the  tracing  and  also  the  name  of 
the  slide  showing  the  record  of  the  sphygmograph  as  dis- 
tinguished from  the  sphygmograph  itself.  The  sphygmogram 
is  traced  on  mica,  as  with  Pond's  sphygmograph  or  on 
paper  as  with  others.  This  tracing  makes  for  the  normal 
pulse  wave  a  curve  showing  an  abrupt  rise  (primary  eleva- 
tion) followed  by  an  abrupt  fall,  after  which  succeeds  a 
gradual  descent,  more  or  less  interrupted  by  secondary  ele- 
vations. The  primary  elevation  (percussion  wave)  and  the 
first  secondary  elevation  (tidal  wave)  correspond  to  the 
systole,  the  third  (dicrotic  elevation)and  fourth  wave  to  the 
diastole  of  the  heart.  The  paper  or  mica  used  for  the 
sphygmograph  is  blackened  by  holding  it  over  a  smoking 
lamp  and  the  tracing  moving  in  accord  with  the  pulsations 
of  the  artery,  indicate  the  strength,  rapidity  and  conformity 
or  otherwise  of  the  pulsebeat. 

The  most  important  matter  connected  with  the  use  of 
this  delicate  instrument  of  precision  in  pulse  testing,  after 
accurate  and  perfect  adjustment  is  to  guard  against  the 
normal  tremor  and  jerky  moevments  <>f  muscle  strain  and 
muscle  tire  and  recording  the  same  on  the  tracings  of  your 
sphygmogram  as  abnormal  pulse  movement.  To  this  en<\  a 
complete  arm  and  wrist  rest  must  be  secured  before  or 
after  fettering  the  wrist  with  the  strap  and  buckle,  prepar- 
atory to  taking  a  record  of  the  pulse  wave.  Some  sphyg- 
mngraphers  have  not  duly  guarded  against  this  complicating 
and    confusing    factor.     The    fingers    should    also    be  kept 


151 

quiescent,  as  their  movements  effect  the  tracings  and  Jike- 
wise,  with  arm  tremor,  may  become  deceptive  tracings  which 
might  be  recorded  as  belonging  to  the  artery  whereas  the 
fault  would  really  be  with  the  muscular  tremor.  To  secure 
the  fingers,  rubber  bands  had  better  be  placed  about'them, 
somewhat  as  we  do  in  steadying  them  where  pen  paralysis 
exists,  except  that  all  the  fingers  of  one  hand  should  be 
embraced  in  one  band,  before  applying  the  button  over  the 
pulse  to  receive  impressions.  The  hand  should  be  kept 
steady,  as  hand  movements  as  well  as  finger  movements, 
and  wrist  movements,  will  effect  the  tracing  on  the  sphyg- 
mogram. 

The  sphygmograph  is  a  valuable  aid  and  supplement 
in  diagnosis  to  the  stethoscope,  pleximeter  and  thermome- 
ter. Its  tracings  are  almost  as  valuable  and  certain,  though 
requiring  extreme  care  in  recording  them,  as  the  revelations 
of  the  speculum  or  endoscope.  In  direct  and  accurate 
differential  diagnosis,  neural  as  well  as  general,  its  use  is 
sometimes  indispensable  and  always  a  satisfaction,  if  you 
have  the  time,  opportunity  and  skill  to  use  it  rightly.  But 
you  should  not  attempt  to  supplant  the  skilled  touch  of  the 
fingers  with  this  instrument.  The  tactiis  eruditus  in  neu- 
rology is  as  essential  as  in  surgery  or  physical  diagnosis. 
Like  the  bruit  of  an  aneurism  and  the  sound  of  anaemia  to 
the  skilled  ear,  the  touch  of  the  full  bounding  pulse  of 
hyperemia,  and  feeble,  small  short  pulse  wave  of  anaemia  are 
matters  of  skilled  perception  which  no  machine  can  impart. 
The  finger  record  of  the  fluttering,  quick,  irregular,  shal- 
low wave  pulse  of  approaching  dissolution  is  as  unerring  to 
the  mind,  through  touch,  as  the  tracing  of  the  sphygmo- 
gram.  They  both  tell  their  tragic  tale  of  the  near  ending 
of  mortality  as  unerringly  as  the  incoherent  delirium  of 
impending  somatic  dissolution. 


152 

The  sphygmograph  gives  you  a  pulse  record.  It  reveals 
arterial  degeneration  states  as  in  cerebral  and  other  arterial 
scleroses.  It  records  states  of  altered  cardiac  innervation 
as  in  dropped  beats,  swtft  beating  tachycardia,  slow  beat- 
ing bradycardia,  etc. 

rhe  sphygmograph  is  a  good  means  of  testing  the 
action  and  efficiency  of  medicines. 

It  is  good  for  making  comparative  records  of  the  two 
sides  and  of  the  pulse  of  the  extremities  with  the  heart's 
beat.  It  is  useful  in  diagnosticating  aneurisms,  anaemia, 
hyperaemia,  sclerosis.  It  should  be  used  more  than  it  has 
been  for  recording  the  pulse  of  and  sequent  to  shock,  the 
pulse  of  neurasthenia,  exophthalmic  goitre,  the  pulse  of 
general  paresis,  hypochondria,  melancholia,  chorea, epilepsia, 
hystero-epilepsia,  mania,  etc.  Dr.  Francis  S.  Kennedy,  in 
a  recent  valuable  and  practicable  article*,  introduces  some 
pertinent   tracings,  which  are    here    shown. 

THE     PEN-HOLDING,    TREMULOUS     HAND    ATTITUDE    OF 

PARALYSIS    AG1TANS. 

(After  Eichhorst.) 

FIG.  83. 


*"The  Sphycmocraph.     Its  Practical  Value."     Brooklyn  Medical  Journal,  July,  1902 


153 


SPHYGMOGRAM    TRACINGS. 

Tracing  of  tremor  of  paralysis  agitans. 

1,  Tremor  of  extensors  of  carpus,  right  hand,  5.3  per  second;  2,  tre- 
mor of  extensors  of  carpus,  right  hand,  5.1  per  second;  3,  tremor  of  head 
while  hands  held  chair,  4.4  per  second;  4  tremor  of  head  while  hands  held 
chair,  4.6  per  socond;  5,  tremor  of  head,  no  effort  with  hands,  4.S  per  sec- 
ond;   6,  tremor  of  single  fingers,  4.5  per  second. 


FIG.  84. 


Ten  Seconds. 


154 


FIG.  85. 


/,W'V/.-';  fr^A^\„ 


&*&&$$!$  \h  J 


''AwW^/iVa' 


A   COMPARATIVE  SERIES  OF  MYOGRAMS  OF  TREMOR. 

1,  Paralysis  agitas;  2,  Basedow's  disease;  3,  multiple  sclerosis; 
4,  hysterical  tremor;    5,  neurasthenic  tremor;    6,  delirium  tremens. 

Tremors  modified  rapidly  recurring  mincature  spasms 
or  as  Peterson  says  they  "are  a  modification  of  the  rhyth- 
mic discharges  of  energy  from  the  motor  ganglion  cells, 
which  occur  at  the  rate  of  ten    per  second.     Consequently, 


155 


when  we  have    fewer    per    second,  it  is    because    of   fusion 
of   two  or  three  impulses." 

Petersen  found  the  tremor  vibrations  in  various  dis- 
eases at  his  nervous  clinic  to  be  "from  3.7  to  5.6  per  sec- 
and,  thus  agreeing  with  all  other  investigators  excepting 
Cowers." 


fig.  86. 

E,  in^  the  figure,  shows 
the  connection  with  the 
battery.  A  regulates  the 
length  of  the  vibration, 
and.  »B,  C  and  D,  are 
appliances  which  only  a 
study  of  this  instrument 
itself  will  render  perfectly 
clear;  pressure  on  F  sets 
the  percuteur  at  work. 
Other  vibrators  accom- 
pany the  instrument  be- 
sides the  one  seen  in  situ. 
Dr.  Granville  began  his 
observations  using  clock- 
work, instead,  of  electric- 
ity, but  for-office  work  he 
prefers  electricity,  and 
uses  the  clock-work  only 
at  the  patient's  house.  Dr. 
Granville  uses  the  percu- 
teur in  locomotor  ataxia, 
some  cases  of  chorea,  for 
the  relief  of  cerebral  and 

cerebro-spinal  irritation  .and  distress,  and  to  elicit  energy 

from  torpid  centers . 


An  American  substitute    for  the   percuteur  is  the  vibra- 
tile.     It    is    less    expensive    and    answers    quite    as  well    for 


156 

ordinary  purpose  s  oi  nerve  excitation.  The  principle  of  its 
construction  and  action  are  the  same,  :/{.,  power,  and  in- 
both    instruments  electric    power,    converted    into   vibratory 

motion  and  this  vibratory  impression  applied  along  the 
course  of  a  nerve  or  over  a  nerve  center,  if  one  could  be 
reached  with  it,  as  for  instance  a  vaso-motor  center,  with 
a  view  "I  bringing  about  a  change  of  action  in  a  morbid 
nerve.  It  acts  as  a  sort  of  a  mechanical  counter  irritation 
and  massage  combined.  This  principle  may  be  applied 
successfully  for  the  relief  of  pain  and  improving  nutrition 
in  a  part,  and  it  is  a  good  method  to  use  in  the  relief  of 
spinal  irritation  and  tender  spine  in  women,  for  suggestive 
psychical  effect  and  for  spinal  myalgia,  which  is  often  a 
morbidly  sensitive  condition  of  the  sensory  nerve  endings 
in  the  muscles  along  the  spine. 

When  in  practice  you  need  to  stimulate  and  change 
molecular  activity  in  a  peripheral  nerve,  employ  the  per- 
cuteur,  the  vibratile  friction  or  other  mechanical  or  chemical 
irritation.  It  will  probably  some  day  be  brought  into  use, 
with  suitable  adjustments,  for  the  purpose  of  influencing 
the  brain  through  the  eyeball  and  the  ear,  as  nerve 
stretching  and  electricity  and  excessve  peripheral  nerve 
irritation  effects  the  respective  peripheral   nerve  centers. 

There  are  many  other  instruments  and  appliances  to 
minutely  satisfy  scientific  curiosity  and  interest  in  precisely 
diagnosticating  states  of  your  patients'  system  with  which 
you  may  wish  to  become  familiar  after  graduation.  Among 
these  are  Huter's  cheiloangescope,  a  microscopic  adjust- 
ment for  seeing  the  living  circulation  in  the  lip.  Another 
is  Antelme's  cephalometer  and  Zernoff's  encephalometer 
which  you  will  find  illustrated  in  Foster's  Dictionary.  The 
circulation  in  the  human  ear  and  in  the  frog's  foot  may 
also  be  seen  with  a  microscope  and  suitable  adjustment. 


CHAPTER  XIV. 

ASCENDING  AND   DESCENDING    DEGENERATION.      REACTION     OF     DEGEN- 
ERATION; WALLER'S    LAW;   ITS   DIAGNOSTIC  SIGNIFICANCE. 


If  a  lesion  involve  the  neurone  or  neurones  of  a  motor 
center,  up  in  the  gray  cortex  of  the  brain,  for  instance,  in 
any  part,  where  those  fan -like  striae  called  corona  radiata 
and  projection  fibers  pass  down  to  go  through  and  between 
the  two  great  basal  ganglia  especially,  through  the  corpus 
striatum  in  that  contracted  white  bundle  of  fibers  which  we 
call  the  internal  capsule,  which  proceed  down  and  contrib- 
ute to  make  the  cruri  cerebri  or  peduncles  of  the  brain,  as  we 
have  so  often  pointed  out  to  you  in  our  dissections,  and 
which  fibers  go  mainly  to  make  up  the  direct  and  crossed 
pyramidal  tracts  of  the  brain  and  cord,  sending  some  fibers 
down  the  cord  directly,  but  chiefly  obliquely  across  and  down 
the  cord  'in  what  is  called  the  decussation  or  crossing  of  its 
pyramids  or  corpora  pyramidalia,  and  neurone  degeneration 
begins  up  there  in  the  cortex,  this  degeneratiou  goes  on 
downward  until  it  meets  with  the  first  sub-station  or  lower 
motor  center  in  an  anterior  horn  of  the  cord.  All  of  the 
motor  fibers  connected  with  the  degenerated  motor  neurones 
of  the  brain  cortex  above,  become  involved  in  the  degener- 
ative process,  from  the  higher  to  the  next  lower  center,  or 
from  station  to  station,  in  the  neuraxis;  that  is,  if  the  motor 
neurone  or  its  neuraxone  is  so  completely  involved  in  dis- 
ease as  to  become  degenerated  or  atrophied. 

[157] 


158 

The  neuraxone  is  practically  prolonged  from  the  neu- 
rone of  the  cortex  till  its  end  tufts  meet  and  touch  the  den- 
drites of  the  lower  neuraxone  in  the  anterior  horn  of  the 
cord.  Investigations  into  the  histogenesis  of  the  structure 
of  the  cord  have  proved  this.  Degeneration  may  be  arrested 
here  or  involve  only  these  neurones  of  the  spinal  cord,  or  it 
may  continue  down  the  cord  and  outward  along  the 
peripheral  nerve.  The  inflammatory  or  other  destructive 
action  may  stop  at  the  first  anterior  horn  or  may  involve  it 
and  go  on  down  the  pyramidal  tract  or  lateral  column  of  the 
cord  on  the  side  opposite  to  the  brain  lesion  or  on  the 
same  side  of  the  cord  lesion,  if  the  injury  or  disease  of  the 
cord  be  below  the  crossing  of  the  fibers  in  the  pyramids. 
If  the  anterior  horn  becomes  involved  along  with  the  lateral 
columns  in  the  diseased  process, as  in  antero-lateral-sclero- 
sis  we  have  motor  nerve  degeneration  and  debility  or 
tremor  or  paralysis,  contracture,  etc.  Later  atrophy  of  the 
innervated  muscles  and  electrical  impression  changes  appear 
in  the  muscles  whose  innervation  is  dependent  on  the 
affected  centers.  This  phenomenon  is  called  the  reaction  of 
degeneration,  and  it  is  an  almost,  if  not  quite,  unerring  sign 
that  the  muscle  tone  and  its  innervating  nerve  center 
integrity  is  lost.  A  like  lesion  of  the  ganglion  neurones 
of  the  posterior  roots  of  the  spinal  cord  will  similarly  in- 
volve in  degeneration  what  represents  its  neuraxone,  the 
tropho-sensory  nerve  fibers  so  far  as  their  distribution  in 
the  skin.  If  trophic  fibers  from  the  anterior  horn  are 
involved,  certain  skin  changes  result,  called  trophic  neurosis 
or  trophoneuroses  of  the  skin.  Degeneration  in  connection 
with  disease  of  the  posterior  column  nerve  center  neurones 
may  also  extend  to  the  posterior  columns  in  the  same 
manner  as  that  of  the  anterior  or  antero-lateral  columns 
extends  downward,  to  the  next  higher  nerve    center,  paral- 


159 

leling,  in  its  manner  of  extending,  anterior  spinal   cord  de- 
generation. 

This  degeneration  may  go  on  till  it  reaches  the  sensory 
neurones  in  the  gray  matter  of  the  brain,  but  it  will  not 
necessarily  involve  them.  Downward  degeneration  of  the 
anterior  and  antero-Iateral  columns  is  called  descending 
degeneration,  and  that  of  the  posterior  columns  is  called 
ascending  degeneration.  Transverse  section  or  disease  of 
the  cord  causes  degeneration  downward  along  the  pyramidal 
or  motor  cord  tracts  and  upward  along  the  columns  of  Goll 
and  cerebellar  columns. 

The  trophic  centers  of  the  sensory  nerves  are  in  the 
intervertebral  ganglia  of  the  posterior  roots.  Their  fibers 
enter  and  cross  the  cord  immediately  after  their  entrance,  to 
ascend  through  the  posterior  columns  to  the  brain.  This  is 
the  deep  decussation.  The  inner,  column  or  columns  of 
Goll  are  made  up  of  long  bundles  of  fibers.  The  outer 
columns  are  shorter,  running  to  the  gray  posterior  horns 
and  make  up  the  column  of  Burdach. 

Long  bundles  of  fibers  also  go  up  to  the  cerebellum  in 
the  lateral  columns  of  the  cord  on  either  side.  In  trau- 
matic transverse  injury  to  the  cord  these  long  and  short 
bundles  of  ascending  fibers  that  make  up  respectively  Golfs 
and  Burdach's  columns  degenerate  upward  from  the  injury. 
Long  bundles  in  the  lateral  columns  also  pass  upward  to 
the  cerebellum  and  help  to  make  the  cerebellar  tract. 

Traumatic  or  disease  lesion  of  the  neurones  and  col- 
umns of  one  side  of  'the  cord  below  the  crossing  of  the 
fibers  at  the  decussion  of  the  pyramidal  strands  cause 
motor  paralysis  on  the  side  of  the  lesion  or  injury  and 
anaesthesia  of  the  opposite  side  and  also  a  circumscribed 
encircling  band  or  bands  of  anaesthesia  around  the  body  on 
a  line  or  slightly  below  the  damaged  spot  in  the  cord  ac- 
cording to  the  distance    below  at  which  the  sensory  nerves 


160 

from  the  injured  cord  center  or  segment  involved,  pass  into  the 
cord.  >( Brown -Sequard's  paralysis.)  See  Gower's  spinal  cord 
segment  and  nerve  exit  and  Brissand's  schemata  for  illustration 
of  Brown -Sequard  crossed  cord  paralysis  at  end  of  chapter. 

Ascending    and     descending    degenerations     cause     the 
truest  and  gravest  types  of  tropho- neurosis. 

WALLER'S  LAW  OF  DEGENERATION  OF  NERVE  TISSUE. 
This  extension  of  disease  in  the  nervous  system  from 
center  to  center,  according  to  the  direction  of  involution 
and  of  function  is  called  the  Wallerian  law.  That  is,  to 
repeat  it  in  another  way  for  illustration,  the  cutting  off  of 
a  nerve  fiber  or  neuraxone  from  its  neurone  or  nerve  cell, 
the  neurone  from  which  the  neuraxone  has  developed  and 
proliferated,  causes  degeneration  along  the  course  of  the 
neuraxone  or  nerve  cell  prolongation.  Let  us  begin  our 
diagramatic  illustration  with  a  point  of  disease,  a  single 
neurone  or  group  of  neurones  in  a  motor  center  of  the 
cortex  and  follow  it  downward  and  out  of  the  cord  as  it 
involves  section  after  section  in  the  projection  fibers  of  the 
motor  tract  within  and  without  the  brain.  This  lesion, 
starting  with  a  neurone  up  there  in  the  cortex  passes  along 
the  neurone's  neuraxone  to  the  dendrites  of  other  neurones 
and  is  there  sent  down  through  other  neurones  going  in  by 
means  of  their  dendrites  and  out  at  their  neuraxones.  From 
cortex,  for  instance,  down  the  corona  radiata,  internal  cap- 
sule, and  cms  cerebri  of  either  side  through  the  pyramidal 
decussation  of  the  medulla  into  the  opposite  lateral  column 
and  thence  to  peripheral  distribution.  A  small  number  of 
fibers  pass  down  directly  and  escape  decussation.  There  ap- 
pear to  be  more  direct  fibers  in  some  neuraxes  or  cerebro- 
spinal axes  than  in  others,  but  not  enough  to  vitiate  the  ana- 
tomical rule  and  the  consequent  physiological  law  of  crossed 
motor  action  from  right  or  left  side  of  brain  to  opposite  side  of 


161 

spinal  column  in  health  and  the  Wallerian  law  of  descending 
degeneration  from  cerebrum  or  cerebellum  to  cord  in  degen- 
erating spinal  cord  disease,  or  cord  center  to  peripheral 
motor  nerve  in  peripheral  descending  degeneration. 

The  neurones  of  the  motor  area  of  the  cerebral  cortex 
contain  the  trophic  centers  of  their  neuraxones.  These 
neurones  appear  to  form,  with  the  pyramidal  tract  fibers, 
nerve  units,  just  as  a  psychic  neurone  and  neuraxone 
does  in  the  gray  cortex  of  the  brain.  Cut  off  the  neuraxone 
or  axis- cylinder  process  from  the  neurone  and  the  neuraxone 
or  fiber  that  goes  down  the  cord  atrophies  and  dies  as  in 
the  accompanying  illustration.  Central  brain  disease, 
destroying  the  neurone  life  and  causing  it  to  atrophy  and 
die,  causes  atrophy  and  death  in  the  projection  connecting 
fibers  and  connected  neurones  below  it.  This  is  called 
descending  degeneration. 

Ordinarily  the  degeneration  is  irreparable,  but  not 
always.  The  central  neurones  of  the  corpus  striatum,  the 
pons,  the  cerebellum  or  the  medulla  may  suffer,  (exception- 
ally only),  from  external  pressure  as  in  neighboring  extra- 
vasation, gummata,  etc.,  which  may  be  removable  and  the 
neurone  degeneration  may  be  arrested  and  recovery  may 
follow.  (Adneural  disease.)  Incurable  transverse  myelitis 
(inter-neural  disease),  may  cause  incurable  degeneration  of 
the  pyramidal  tracts  below  the  lesion;  or  a  removable  ad- 
ventitia  may  oppress  the  cord  but  be  removed  by  specific 
treatment  and  electricity  and  the  descending  degeneration 
may  be  arrested.    (Extra-neural  disease  also.) 

The  law  of  Waller  briefly  stated  is  that  the  motor 
conducting  paths  degenerate  downward  while  the  sensory 
paths  degenerate  upward,  and  while  this  law  is  "not  abso- 
lute and  may  be  shattered"  as  Mayer,  who  has  so  ably 
translated  Oppenheim,  says,  it  is  a  good  general  law,  and 
its  understanding  will  aid  you  in  prognosis. 


162 

In  main-  matters  in  neurology  we  stand  yet,  as  Edinger 
Ikis  stimewhere  so  well  said,  "in  the  current  of  changing 
opinions,  receiving  daily  new  contributions."  The  myelin 
sheath  of  the  neuraxone  or  axis-cylinder  process  of  a  cen- 
tral neurone  and  of  a  peripheral  nerve  is  formed  from  many 
cells,  which  have  an  independent  though  common  epiblastic 
origin  and  conditions  of  central  irritation  going  to  periphery 
may  modify  or  arrest  central  control  degenerative  influena  , 
such  as  persistent  well  regulated  exercise  in  the  thera- 
peutics of  locomotor  ataxia;  the  exercise  connected  with 
the  dorsal  decubitus  nerve-stretching,  and  bathing,  swim- 
ming in  warm  sulphur  water  pools,  which  latter  I  especially 
recommend  in  this  formidable  disease  of  posterior  columns 
of  the  cord.  The  exercise  treatment  of  tabetic  ataxia  by 
Frenkel,  of  "  Friehof "  Sanatorium,  in  Heiden,  Switzerland, 
trains  the  central,  through  peripheral  impression  neurones, 
though  this  author  does  not  appear  to  see  the  subject  in 
this  light,  for  he  rejects  both  the  center  and  the  sensory 
theories  of  locomotor  ataxia. 

Section  of  a  nerve  causes  the  death  of  its  axis-cylinder. 
The  axis-cylinder  of  a  nerve  seems  in  health  to  modify  and 
regulate  the  nutrition  of  its  surrounding  myeline  cells, main- 
taining their  activity  in  a  certain  normal  way  and  promoting 
or  keeping  up  the  fatty  metabolisms  of  the  myeline  cells 
and  regulating  the  growth  of  protoplasm.  On  the  death  of 
the  axis-cylinder  of  a  nerve  the  myeline  cells  suddenly 
increase  for  a  time  in  size  and  activity,  and  then  exhaust  and 
shrink  and  become  atrophied  and  degenerate.  A  peripheral 
nerve  loses  its  irritability  in  man  completely  within  forty- 
eight  hours  after  section  and  its  conductivity  immediately,  from 
center  to  circumference  and  vice  versa.  I  could  tell  you  much 
more  on  this  subject  than  you  could  now  receive,  if  we  had 
the  time,  and  more  than  you  might  now  in  the  rush  of  this 


163 

course  fully  comprehend.  When  you  have  leisure  for  it, 
consult  Obersteiner  on  neurohistogeny  and  secondary 
degeneration,  or  Barker,  His,  and  other  authors  on  this  inter- 
esting subject. 

Artificially  produced  secondary  degeneration  as  first 
practiced  experimentally  by  Waller  has  been  of  great  serv- 
ice to  neurology  and  to  neuriatry,  enabling  us  to  know  the 
location  and  effects  of  certain  diseases,  for  the  results  of 
experimental  injury  to  a  part  of  the  nervous  system  are 
quite  similar  to  those  caused  by  destructive  disease.  And 
this  is  the  reason  experimental  physiological  science  cannot 
yield  to  the  clamor  of  the  anti-vivi-sectionist,  though  it 
should  be  as  humane  and  painless  as  possible  and  it  ordi- 
narily is  painless  in  most  of  its  methods. 

Waller  showed  by  vivisection  that  when  an  anterior 
spinal  nerve  root  is  cut  the  fibers  below  the  section  died 
and  it  could  have  been  demonstrated  in  no  other  way.  The 
distal  portions  of  the  root  degenerate  and  the  fibers  which 
supply  the  anterior  root  to  the  compound  nerve  and  that 
when  the  posterior  root  is  cut  proximately  to  its  ganglion, 
that  is  between  its  ganglion  and  the  nerve  root  origin  in 
the  posterior  columns  of  the  cord,  all  of  its  fibers  die 
between  the  point  of  section  and  the  cord,  while  all  the 
fibers  between  the  section  and  the  ganglion,  /'.  e.,  all  the 
fibers  distally  to  the  section  live.  A  small  portion  of  fibers 
of  the  posterior  root  (not  many) have  trophic  centers  beyond 
the  posterior  root  and  external  or  distal  to  it  toward  the 
periphery.  This  accounts  for  the  slight  modification  of  the 
law.  It  is  one  of  nature's  conservative  ways,  such  as  we 
are  accustomed  to  see  so  often  and  elsewhere,  in  her  wise 
provision  for  the  saving  of  man  from  total  destruction;  such 
as  we  see  in  some  of  the  lesser  vicarious  paths  of  motor 
conduction  down  the  cord,  as  we  see  in  some  of  the  com- 
paratively few  strands  that  go  down  the  direct  anterior 
columns  of   the  cord — the  columns  of  Turck. 


FIG.  87. 


FIG. 


FIG.  S9. 


-ascending  and 
Descending  Degener- 
ation in  the  Spinal 
Cord.  A,  primary  area 
of  degeneration  (lesion). 
fl,  degeneration  of  Coil's 
columns  (ascending).  C, 
degeneration  of  Ihe 
crossed  pyramidal  tract 
(descending).  (After 

Gowers.) 


SCHEMA  OF  GOWER'S  SPINAL 

CORD  SEGMENTS  AND 

NERVE   EXITS. 


FIG.   90. 


FIG.  91. 


cd< 


The  mutual  relations  of  the 
vertebral  bodies  and  spines 
to  the  segments  in  the  eordi 
and  to  the  exits  of  the  nerves- 
(Gowere). 


Wallerian  degeneration  of 
nerve  Sores  after  section.  /,  nor> 
mal  nerve  fibre  ;  II  and  IJJ,  gores 
■showing  different  degrees  of  degen- 
eration ;  .«  neurilemma  j  m,  medul- 
lary sheath  ;  A,  axone  ;  i,  nucleus 
of  neurilemma  cell ;  L,  marking  of 
Lantermann  ;  R,  node  of  Ranvier ; 
mt,  drops  of  myelin  ;  a,  remains  of 
axone ;  jr.  proliferating  cells  of 
neurilemma.  Partlv  s-hematic 
Utter  Thoma.|_^m  %&gj* 


CHAPTER   XV. 

THI:  REACTION  OF  DEGENERATION  AND  ITS  USE  IN  DIAGNOSIS.      HOW  TO 
DISCOVER  IT.     APPLICABLE   CASES. 


We  have  seen  how  peripheral  motor  nerves  and  motor 
conducting  nerve  paths  in  the  neuraxis  degenerate  when 
separated  from  their  proper  centers — their  trophic  {Tpofai — 
nutrition)  or  nutritional  centers, so  closely  connected  with  motor 
centers  that  motor  center  disease, (and  motor  centers  and  tro- 
phic centers  are  near  neighbors  in  the  cord),  often  causes 
decay  of  nutrition  and  also  peripheral  inaction  as  in  mus- 
cular debility  from  lack  of  muscular  exercise.  Well,  when 
the  cerebro-spinal  centers  of  motion  are  gravely  diseased 
or  injured  so  as  to  cause  central  destruction  or  solution  of 
continuity  in  the  cells  of  the  central  or  peripheral  nerve 
mechanism,  of  course  conductivity  of  willed  impulses  is 
impossible,  the  neighboring  trophic  centers  often  become 
likewise  involved  and  a  corresponding  change  in  the  nor- 
mal response  of  nerve  supplied  muscle  appears  on  applica- 
tion of  electrical  tests.  This  was  named  by  Professor  Erb, 
of  Heidelberg,  who  first  described  it,  the  reaction  of  degen- 
eration. It  is  a  nerve  muscle  degeneration  reaction  to  ordi- 
nary electrical  impression  characterized  by  these  peculiari- 
ties, vi%: 

Muscular  contractility  diminishes  for  both  the  faradic  and 
galvanic  currents  when  neuro-muscular  degeneration  exists. 

After     about    two    weeks     from    the    beginning  of    the 

[164] 


165 

degenerative  process,  the  effected  muscle  ceases  to  respond 
to  the  will  or  direct  electrical  current. 

The  direct  faradic  current  irritability  of  the  muscle 
diminishes  and  then  disappears.  The  galvanic  irritability 
disappears  also. 

Responsiveness  or  irritability  to  electrical  excitation 
returns  again  after  a  time  for  the  galvanic  current, the  muscu- 
lar contractions  occurring  from  a  very  weak  current,  but 
with  a  peculiar  deliberation  of  movement  not  to  be  seen  in  any 
other  muscular  contraction  under  electric  excitation.  It  is 
what  might  well  be  called  the  retreating  wave  of  neuro- 
muscular degeneracy.  It  is  like  the  secondary  retreating  wave 
that  follows  from  the  shallow  shore  back  to  the  sea  after  the 
great  sea  waves  have  spent  themselves  on  the   strand. 

These  electro-neuro-muscular  waves  are  sluggish, 
slow,  long  drawn  out  muscular  contractions  which  suggest 
expiring  or  spent  power.  They  are  singular  and  suggestive 
of  exhaustion,  reminding  one  of  the  protest  of  weakness  in 
a  hopeless  struggle.     And  so  they  are. 

In  contrast,  normal  neuro-muscular  contraction  under 
the  stimulus  of  certain  faradic  currents  are  short,  quick, 
abrupt  and  vigorous.  The  same  intensity  of  galvanism 
that  gives  the  peculiar  degeneration  contraction  would  not 
contract  the  healthy  muscle  at  all. 

The  electrical  formula  is  changed,  i.  e.,  the  polar  reac- 
tions alter  in  sequence, and  muscular  contractions  are  changed 
in  contrast  with  ordinary  muscular  reactions  under  electric- 
ity. The  cathodal  (carbon,  positive  pole)  closing  con- 
traction of  the  reaction  of  degeneration  takes  place  under 
the  same  or  under  a  weaker  current  than  cathodal  closing 
(zinc,  negative  pole)  contraction.  A  cathodal  closing 
tetanus  like  contraction  and  the  anodal  opening  contraction 
appear  as  the    same.     This    is  a  change    in  electrical    con- 


166 

traction    compared     with     healthy     electrical     excitation — a 
change  in  the  formula,  in  the  language  of  electro-diagnosis. 

If  the  nervous  disease  is  above  the  trophic  center  in 
the  neuraxis  which  innervates  the  nerve  going  to  the  supply 
of  the  muscle  we  are  examining,  the  paralyzed  muscle,  as 
for  instance  in  apoplectic  disease  of  the  brain,  there  will 
be  no  reaction  of  degeneration,  unless  secondary  degenera- 
tive change  sets  in  as  a  chronic  sequence,  which  is  rare. 

In  accordance  with  Waller's  law  the  disease  descends 
down  to  the  trophic  centers  of  the  cord  and  implicates  them 
in  destruction.  That  is,  if  a  degenerative  lesion,  for  ex- 
ample, attacks  the  cms  cerebri  of  either  side  of  the  brain  it 
passes  down  the  antero-lateral  pyramidal  tracts,  (following 
the  projection  tracts  which  we  have  been  talking  about), 
to  the  tropho- motor  centers  of  the  cord  and  destroying 
them,  then  degenerative  muscular  atrophy  appears  and  with 
this  destruction  of  the  motor  and  trophic  cord  centers 
appears  Erb's  characteristic  reaction  of  degeneration  to 
electrical  stimuli. 

You  must  carry  in  your  mind  a  little  electrical  knowl- 
edge in  order  to  intelligently  apply  the  diagnostic  test  for 
the  reaction  of  degeneration,  which  we  might  more  defi- 
nitely call  the  galvanic  electric  reaction  degenerative  change. 
For  this  is  what  it  is.  Its  peculiarly  slow  contraction  to 
galvanism  is  the  chief  characteristic  of  the  reaction  of 
degeneration  and  to  very  feeble  galvanic  currents. 

The  current  goes  from  anode  (that  is  the  plus  or  positive 
carbon  pole)  to  cathode  (that  is  the  negative  or  zinc  pole) 
always.  The  positive  pole  must  be  a  diffuse,  wet  sponge, 
chamois  or  cloth  electrode.  The  negative  pole  should  be 
a  smaller  sponge  or  metal  point,  disc  or  brush  electrode. 
But  always  applied  to  a  moist  surface.  Both  electrode 
or  the  skin  should    be    wet.     The    cathode  is  the    negative 


167 

pole  or  electrode.  The  anode  is  the  positive  pole  electrode. 
Contractions  occur  on  opening,  closing  or  suddenly  altering 
the  strength  of  the  electric  current.  The  effects  of  the 
current  are  uniform  on  all  healthy  muscles.  Effects  are 
variable  where  muscular  innervation  is  diseased;  i.  e.,  im- 
paired or  destroyed. 

The  faradic  current  is  a  succession  of  rapid  interrup- 
tions. To  produce  contractions  the  galvanic  current  must 
be  interrupted  with  an  interrupter  to  break  the  current, 
located  in  the  handle  of  the  electrode  or  on  the  battery, 
or  the  current  otherwise  broken  or  suddenly  changed. 

(Those  of  you  who  use  the  little  book  of  Seifert  and 
Muller  for  reference  must  fix  in  your  mind  well  the  German 
words,  Oeffnung,  meaning  opening,  symbol  O;  Schliesing, 
meaning  closing,  symbol  S;  and  Zuckung  for  contraction 
and  they  are  not  pronounced  as  they  are  spelled,  either. 
The  first  is  pronounced  effnunk,  the  second  sleezing  and 
the  third  zookoonk  or  else  1  am  no  philologist,  which  is 
probably  the  fact,)  Thus  you  have  C.  C.  C,  A.  C.  C,  A. 
O.  C,  C.  O.  C,  in  health.  In  reaction  of  degeneration  the 
formula  of  contraction  would  be  like  this:  A.  C.  C,  C.C. 
C,  C.  O.  C,  A.  O.  C,  English  formula.     Compare  them. 

The  reaction  of  degeneration  is  electrically  revealed  in 
destructive  peripheral  nerve  lesion,  like  rheumatic,  plumbic 
diphtheritic, cerebro-spinal  meningitic,  syphilitic  and  alcoholic 
paralysis,  with  destructive  neuritides  and  in  poliomyelitis 
anterior,  where  the  gray  anterior  cornua  are  destroyed  by 
inflammation  and  in  transverse  myelitis,  amyotrophic  lateral 
sclerosis,  progressive  muscular  atrophy,  bulbar  paralysis.  In 
brain  paralysis  not  involving  lower  trophic  centers,  as  we 
have  said,  when  discussing  descending  Wallerian  degenera- 
tion, we  do  not  find  the  reaction  of  degeneration  sign. 

Continuing  fibrillary  contractions,  such  as  those  of  pro- 


16S 

gressive  muscular  atrophy,  often  appears  In  the  muscles  that 
show  the  phenomenon  of  reaction  of  degeneration.  The 
neuro- muscular  action  change  in  athetosis  and  tremor  being 
caused  by  defective  innervation,  is  somewhat  akin  to  some 
phases  of  muscular  reaction  in  partial  reaction  ol  defeneration. 
In  s  >me  cases  of  central  nerve  degeneration  you  may  have 
hyper- excitability  to  direct  galvanic  irritation  of  muscles, 
anodal  closure  contraction,  then  cathodal  closure  contraction 
and  always,  if  real  reaction  of  degeneration  be  present, 
the  peculiar  characteristic  deliberate  contraction  already  re- 
ferred to. 

As  galvano-muscular  irritability  and  the  peculiar  reac- 
tion of  degeneration  disappear  entirely  in  a  few  months 
after  degenerative  motor  nerve  disease  appears,  the  sign  of 
reaction  of  degeneration  is  not  of  diagnostic  value  in  very 
chronic   cases. 

Muscular  tissue  in  its  normal  condition  of  healthy 
moisture,  is  itself  a  good  conductor  of  electricity  and  even 
dead  muscles,  as  in  Galvani's  celebrated  laboratory  discovery 
and  subsequent  experiments  have  amply  proven,  so  that 
something  more  than  loss  of  nerve  conductivity  takes  place 
where  the  reaction  of  degeneration  shows  and  where  all 
muscular  contractility  finally  disappears,  under  electricity. 
The  atrophied  muscle  itself  ceases  to  be  so  good  a  conduc- 
tor as  it  was  before.  The  remaining  bulk  and  moisture 
(oil  globules,  etc.,)  in  pseudo-hypertrophic  muscular  paralysis 
(in  which  the  muscle  circumference  is  great  and  power 
feeble)  is  perhaps  the  reason  why  the  reaction  of  degener- 
ation does  not  show  in  this  disease  and  the  muscles  do 
not  correspond  in  normal  like  contraction,  notwithstanding 
the  persisting  integrity  of  some  of  the  muscular  libers. 

The  chief  value  of  the  reaction  of  degeneration  sign,  is 
in  helping    us  to    detect    true  degenerative,    from  the  false 


169 

hysterical  evanescent  functional  paralyses.  You  may  have 
use  for  it  in  litigation  cases  before  the  courts.  When  found, 
this  sign  is  a  pretty  good  and  positive  proof,  like  the 
microscopic  evidences  of  degeneration  in  the  piece  of  har- 
pooned muscle  taken  from  a  progressive  muscular  atrophic, 
but  the  absence  of  this  sign  does  not  disprove  the 
existence  of  real  degenerative  motor  paralysis.  The  time 
for  the  test  may  have  passed  before  you  apply  it.  There 
may  be  conditions  that  supplement  the  change  in  muscular 
conductivity  and  impressibility  ordinarily  wrought  by  the 
degenerative  forms  of  paralysis.  It  is  a  proof  when  you 
find  it,  but  not  a  disproof  when  you  fail  to  find  it. 

The  estimate  of  the  force  or  intensity  of  electricity  is 
made  by  the  number  and  size  of  the  elements  employed  or 
by  the  galvanometric  or  millimeter  record. 

"According  to  Ohm's  law  I=JJ;  that  is  the  strength  of 
the  current  or  intensity  (I)  is  in  proportion  to  the  electro- 
motive force  (E,  number  of  elements)  and  is  in  inverse 
proportion  to  the  whole  amount  of  the  resistance  present 
in  the  electric  current.  Now  an  ampere  is  that  strength  of 
current  (1)  which  is  generated  by  the  electro- motive  force 
(E)  of  1  volt  in  an  erectric  current  of  resistance  (W)  of  1 
ohm.  An  ampere  then,  is  equal  to  {  ™£.  One  volt  is  equal 
to  nine-tenths  of  the  electro -motive  force  of  a  Daniel  ele- 
ment; one  ohm  is  equal  to  a  column  of  mercury  106  centi- 
meters long,  and  one  square  millimeter  in  section  (1.06 
Siemen's  unit).  For  medical  purposes,  no  strength  of  cur- 
rent higher  than  twenty  thousandths  (milli)  amperes  is 
used.  With  motor  nerves  superficially  situated  cathodal 
closing  contraction  occurs  normally  with  currents  of  li  MA 
strength." 

The  strength  of  the  current  may  be  varied  either  by 
inserting  many  or  few  elements,  or  by  means  of  a  rheostat, 


170 

by  which    resistance  of    different  degrees    may    be  inserted 
into  the  current. 

In  the  recent  clinics  you  have  noticed  that  the  reaction 
of  degeneration  has  not  been  elicited.  That  is  because  the 
cases  shown  have  been  so  chronic  that  the  time  for  any 
electro -muscular  excitability  has  long  since  passed  in  the 
chronic  myelites  and  progressive  muscular  atrophies,  etc., 
exhibited. 


fig.  92. 


CHAPTER   XVI. 

HOW  THE  REACTION  OF  DEGENERATION  IS  DIAGNOSTICATED. 


The  reaction  of  degeneration  is  elicited  by  electrical 
test. 

The  electric  impressibility  to  both  galvanism  and 
faradism  diminishes  and  disappears  after  about  two  weeks 
from  the  commencement  of  the  nerve  center  or  nerve 
tract  degenerative  processes  affecting  the  connected 
muscles  which  are  involved  atrophically  in  the  degenerative 
process.  Conductivity  to  both  the  current  and  will,  are 
lost  simultaneously. 

The  first  thing  to  note  is  that  direct  irritability  in  the 
muscles  lessens  and  finally  disappears  for  a  time. 

The  next  thing  to  note  is  that  the  muscular  irritability 
reappears  to  galvanism  in  about  fourteen  days. 

The  next  thing  to  note  is  that  the  very  weakest  gal- 
vanic currents  cause  contractions  and  finally  it  is  to  be 
noted  that  the  resulting  contractions  are  peculiarly  slow, 
jeeble  and  very  deliberate. 

The  sensori  motor  nervous  system  now  seems  dead  in 
its  responses  to  faradic  impression  and  to  feebly  stammer 
in  its  responses  to  galvanic  electricity.  If  it  could  speak 
it  would  only  slowly  stutter  in  speech. 

The  voluntary  musdes  supplied  by  the  sensory 
motor  nervous  system  are    therefore    peculiarly    changed  in 

[171] 


172 

responsive  reactions  to  electric  excitability  in  the  morbid 
nervous-  phenomena  called  the  reaction  of  degeneration. 

This  much  you  need  absolutely  to  know  in  general  in 
order  to  assure  yourself  that  reaction  of  degeneration  is 
present  in  a  given  case. 

But  there  is  a  farther  test  in  the  changed  electric  for- 
mulary. 

The  normal  muscular  reactions  to  indirect  electricity 
(gradually  increasing  the  intensity  of  the  current)  are  as 
follows: 

a.  Cathodal  (negative)  closing  contraction,  C.  C.  C. 
(or  in  the  German  formula  Ka.  O.  Z.). 

/'.  Anodal  (positive)  opening  contraction,  A.  O.  C. 
or  (An.  O.  Z.). 

c.  Anodal  (positive)  closing  contraction.  A.  C.  C.  or 
An.   S.  Z. 

d.  Cathodal  closing  tetanic,  (longer  continued)  contrac- 
tion.     C.  C.  T.      (Ka.  S.  Z.)   lasting  through  contraction. 

Cathodal  closing.  C.  C.  or  (Ka.  S.)  and  finally 
cathodal  opening  contraction.     C.  O.  C.  or  Ka.  O. 

This  is  the  law  of  response  to  healthy  indirect  elec- 
trical irritation  of  the  nerves  as  shown  through  the  action 
of  the  muscular  system.  It  may  be  likened  to  a  man  in 
see-saw  movement  of  the  muscles  and  reads  C.  C.  C. ; 
A.  O.   C;     A.  C.  C;     C.  C.  C.    (tetanic). 

On  the  contrary  in  the  reaction  of  degeneration  the 
formula  of  contraction  is  changed  to  read  thus:  A.  C.  C. 
(An.  S.  Z.),  takes  place  with  the  same  current  as  the 
C.  C.  C.  (Ka.  S.  Z.),  or  a  current  of  less  strength  and 
the  C.  O.  C.  (Ka.  O.  Z.),  shows  the  same  as  the 
A.  O.  C.  (An.  O.  Z.),  that  is  the  anodal  closing  con- 
traction and  the  cathodal  closing  contraction  give  the  same 
result  and  the  cathodal  opening  and  the  anodal  opening 
contractions  show  the  same. 


\7S 

In  a  month  or  so  galvano-muscular  instability  dimin- 
ishes and  by  three  months  has  usually  disappeared  entirely 
not  to  return  again  ordinarily. 

Should  recovery  take  place  (which  is  exceptional) 
electric  irritability  returns  tardily  to  the  normal  reaction 
display. 

Trophic  central  and  volitional  influences  however  are 
more  potent  than  the  electric  fluid  to  excite  muscular  re- 
sponse when  the  degenerative  processes  are  replaced  by 
reconstructive  regeneration.  Muscular  tones  and  voluntary 
motion  then  reappear  markedly,  while  normal  electrical 
reaction  comes  back  to  the  affected  muscle  slowly. 

When  the  reaction  of  degeneration  is  modified  in  de- 
gree, it  is  called  partial  reaction  of  degeneration  and  shows 
that  the  motor  center  or  motor  conduction  paths  are  not 
completely  destroyed.  Some  of  the  neurones  of  the  center 
and  some  of  the  nerve  fibers  remain  intact.  In  such  case 
nervous  irritability  to  both  faradism  and  galvanism  permit, 
if  the  currents  are  applied  directly  and  contractility  is  the 
result. 

We  sometimes  have  partial  reactions  of  degeneration 
from  incomplete  lesions  of  the  peripheral  nervous  system, 
as  in  alcoholic,  rheumatic,  diphtheritic,  spinal  meningitis, 
la  grippe  or  other  neurotoxic  conditions  and  from  hystero- 
neurotic  influences. 

Sometimes  these  toxic  adneural  influences  are  power- 
ful enough  and  destructive  enough  to  destroy  reaction  of 
degeneration  altogether  but  they  do  not  do  this  so  often  or 
so  completely  as  the  inter-neural  organic  changes.  Com- 
plete peripheral  traumatisms  also  cause  reaction  of  degen- 
eration. 

But  the  most  usual  conditions  causing  complete  reac- 
tion of  degeneration    are  poliomyelitis,  anterior    infantilis  or 


174 

other  involvement  of  the  gray  matter  of  the  anterior  horns 
of  the  spinal  cord  and  transverse  myelitis  or  other  dis- 
eases implicating  the  spinal  cord  clear  across  in  destruc- 
tion. When  the  gray  nuclei  of  the  medulla  are  destroyed 
by  extensive  plumbism  we  may  have  complete  the  reac- 
tion of  degeneration  in  lead  paralysis.  We  find  this 
reaction  often  in  particular  muscles  in  progressive  muscular 
atrophy  and  sometimes  in  bulbar  paralysis,  amyotrophic 
lateral  sclerosis  and  other  nerve -center  diseases. 

WHEN   THE   REACTION  OF  DEGENERATION   MAY   PERSIST 
WITH   NERVE-CENTER  DISEASE. 

Whenever  the  entire  nerve  center  connection  is  or  its 
peripheral  nerve  connections  are  almost  entirely  destroyed 
we  may  have  this  peculiar  reaction. 

When  the  higher  centers  of  the  neuraxis  above  the 
medulla  are  destroyed  we  do  not  have  the  reaction  of  de- 
generation unless  the  disease  descends  down  the  cord  and 
involved  its  centers  and    tracts   (descending  degeneration.). 

The  reaction  of  degeneration  is  therefore  not  present 
in  recent  apoplexies  causing  brain  hemiplegias  or  in  those 
exceptional  basal  brain  apoplexias    which    cause  paraplegia. 

In  plain  local  myopathic  paralysis  you  would  not  be 
apt  to  find  reaction  of  degeneration. 

The  spinal  cord  center  must  be  involved  in  destructive 
disease  to  give  reaction  of  degeneration  to  muscles  innerv- 
ated from  that  particular  center  of  the  cord. 

Degenerative  atrophy  of  muscles  is  associated  with 
trophic  atrophy— the  two  go  together— the  atrophy  giving 
the  reaction  is  the  atrophy  of  degeneration. 

Atrophy  from  central  disease  does  not  necessarily  give 
reaction  of   degeneration. 


175 

Feeble  fibrillary  contractions  appear  in  muscular  areas 
once  innervated  by  degenerated  nerve  centers  showing  re- 
action of  degeneration. 

They  are  characteristic  of  progressive  muscular  atrophy. 

Limited  central  cord  disease  or  disease  of  its  circum- 
ference not  involving  the  gray  cornua  as  aneurism,  embolism 
or  tumor,  does  not  give  reaction  of  degeneration. 

Absolute  and  entire  destruction  of  all  nerve  fibers  and 
nerve  center  neurones  do  not  take  place  in  such  palsies  as 
show  reaction  of  degeneration  until  after  all  reaction 
phenomena  disappear  entirely,  after  the  second  or  third 
month.  A  solitary  central  neurone  or  so  and  a  few  con- 
ducting nerve  fibers  must  remain,  with  some  functioning 
form  to  show  even  the  feeble  response  of  the  phenomenon 
of  the  reaction  of  degeneration. 

A  muscle  undergoing  atrophy  from  degeneration  of  its 
nerve  center  or  connecting  peripheral  nerve,  ceases  to  re- 
spond to  the  different  forms  of  electricity  in  the  following 
order,  viz. :  first  to  static  electricity,  then  to  faradic,  then 
to  the  interrupted  galvanic  and  finally  to  the  galvanic  cur- 
rent, the  voltaic  alternative,  that  is  by  suddenly  reversing  it. 

Gentlemen — it  is  the  vaso  motor  influence  of  the  gal- 
vanic current  and  its  precedent  influence  on  the  neurones 
upon  which  we  rely  in  its  therapeutic  use.  If  it  can  so 
demonstrably  affect  the  vaso  motor  centers  as  to  contract 
abnormally  dilated  arterioles  through  their  influence  and 
thus  physiologically  regulate  blood  supply  and  promote 
normal  neurone  nutrition  by  overcoming  abnormal  blood 
pressure  we  need  not  invoke  a  hypothetical  catalytic  action 
to  justify  the  employment  of  constant  galvanism  in  all 
hyperasmic  states  of  nerve  centers  that  may  be  impressed 
through  the  vaso  motor  system  and    its  constrictor  fibers. 

Erb    in    his    "Handbuch    der    Electrotherapie"    doubts 


176 

this,  and  he  is  a  great  German  neurologist  of  repute.  He 
doubted  it  twenty  years  ago  but  so  did  others.  1  was 
then  demonstrating  the  contrary  and  so,  1  think,  were  La- 
borde  and  Latournian. 

Erb  employed  a  large  head  electrode  covered  with  a  sponge 
like  the  one  shown  in  the  cut  of  your  text-books,  but  an  ordi- 
nary wet  sponge  electrode  the  anode  or  positive  pole  to  the 
forehead  and  the  negative  to  the  nape  of  the  neck  will 
answer.  He  passed  weak  currents  through  the  head  with- 
out break  from  one  to  two  minutes.  One  minute  is  ordi- 
naiily  enough.  When  you  take  off  the  current  take  it  off 
very  gradually  so  as  not  to  cause  vertigo  by  sudden  with- 
drawal and  filling  of  the  contracted  blood  vessels.  You  would 
nut  suddenly  take  off  the  abdominal  bandage  after  tapping 
for  dropsy.  The  oblique  currents  are  preferable.  That  is, 
from  right  or  left  forehead  to  center  of  neck  behind.  1  do  not 
advise  the  transverse  currents,  /'.  <'.  from  temple  to  temple. 

1  must  caution  you  while  you  search  for  the  reaction 
of  degeneration  or  for  evidence  of  that  advanced  chronic 
degeneration  which  has  passed  all  reaction  stage  and  shows 
no  response  in  kind  or  quality  to  electricity,  that  con- 
ductivity in  the  dry  skin  is  nil,  or  resistance  as  the  elec- 
tricians say  is  extreme,  so  that  you  must  thoroughly 
moisten  the  epidermis,  (with  warm  water  preferably).  You 
must  also  keep  the  current  on  a  long  time,  and  closed, 
and  without  changing  the  number  of  elements,  before  giv- 
ing up  the  test.  Sometimes  currents  which  are  not  felt  in 
the  beginning  finally,  if  applied  this  way,  break  down  re- 
sistance in  the  skin  and  cause  contraction  and  even  pain. 
Apply  the  current  long  enough  to  feel  assured  that  the 
skin  is  wet  through  and  permeated  with  it.  If  you  reach 
the  superficial  motor  nerves  with  your  moist  electrodes 
cathodal  closing  contraction    ought    to    occur    normally  with 


177 

currents  of  from  one  to  three  milleampere  meter  strength. 
Be  not  too  hasty  to  conclude  that  there  is  no  reaction. 
Make  the  test  thorough  before  deciding.  A  current  may 
not  be  felt  at  first  and  yet  by  constant  and  persistent  ap- 
plication its  intensity  increases  and  its  effect  is  seen  and 
felt. 


CHAPTEK    XVII. 

ANOTHER   VIEW  OF  THE   REACTION   OF   DEGENERATION. 


Objection  has  been  raised  to  the  views  presented  in 
the  preceding  lecture,  which  1  here  give  from  the  best  and 
most  eminent  source,  together  with  my  views  thereon. 
Barker,  who  sustains  his  statements  with  excellent  con- 
firmatory illustrations,  in  discussing  the  other  side,  after 
presenting  the  current  conception  of  Waller  and  his  fol- 
lowers, says: 

'  The  application  of  the  Wallerian  doctrine  has  aided 
immensely  in  unraveling  the  complicated  relations  existing 
inside  the  central  nervous  system.  Thus,  in  a  transverse 
lesion  of  the  cord,  for  the  bands  of  fibres  which  degenerate 
in  sections  above  the  site  of  the  injury,  the  'trophic 
centers,'  /.  c,  their  cells  (of  origin)  are  to  be  sought  below 
this  level,  and  vice  versa,  the  cells  of  origin  for  tracts  which 
degenerate  in  sections  below  the  level  of  injury  must  be 
situated   somewhere  above  this  level. 

"Since  the  time  of  Waller  and  Turck  the  histology  of 
the  degeneration  of  nerve  fibres  after  separation  from  their 
cells  of  origin  has  been  studied  by  many — notably  by  Ran- 
vier,  Homen  (of  Helsingfors),  Howell  and  Huber,  and  Tooth. 
The  last,  in  the  interesting  Gulstonian  Lectures  for  1889, 
has  reviewed  succinctly  the  facts  up  to  that  date.  The 
studies  of  von    Notthaft  are  of   especial  value,  in  that  they 

[17S] 


179 

have  yielded  definite  information  concerning  the  state  of 
nerve  fibres  at  various  periods  after  the  lesion.  This  in- 
vestigator divides  the  changes  which  occur  in  a  nerve  after 
section  into  two  stages.  The  first  stage  includes  those 
which  occur  during  the  first  three  days.  These  alterations, 
which  consist  in  fragmentation  of  the  myelin  and  of  the 
axone  in  the  first  one  or  two  internodes  on  each  side  of 
the  lesion,  are,  Notthaft  believes,  the  direct  result  of  the 
trauma.  The  true  Wallerian  degeneration  (or  the  second 
stage)  begins  on  the  second  or  third  day  in  the  fibre  distal 
to  the  lesion,  and  is  the  result  of  severance  of  connection 
with  the  central  end,  and  not  the  direct  result  of  the 
trauma.  The  axone  swells  and  fragments,  and  the  myelin 
breaks  up  into  droplets  along  the  whole  length  of  the 
nerve.  Multiplication  of  the  nuclei  of  the  neurilemma  is  ev- 
ident at  the  fourth  day.  At  the  sixth  or  seventh  day 
liquefaction  of  the  myelin  commences,  and  this  continues 
until  the  sixtieth  or  eightieth  day,  by  which  time  all  the 
myelin  has  been  liquefied  and  a  large  part  of  it  has  been 
absorbed.  After  three  or  four  months  the  myelin  has  en- 
tirely disappeared. 

"During  the  secondary  degeneration  of  the  white  fibres 
within  the  central  nervous  system  there  is  a  proliferation 
of  the  neuroglia.  The  multiplication  of  the  neuroglia  cells 
begins  in  the  white  matter,  according  to  Ceni,  some  forty- 
five  or  fifty  days  after  the  lesion.  The  neuroglia  cells 
cease  to  multiply  at  about  the  hundredth  day,  after  which 
there  is  a  gradual  disappearance  of  neuroglia  nuclei  with 
gradually  progressing  sclerotic  change. 

"Owing  to  the  shortness  of  the  dendrites  (unless  we 
look  upon  the  peripheral  sensory  fibre  as  a  dendrite),  we 
possess  no  exact  studies  concerning  their  fate  when  sev- 
ered from  the  cell  bodies  of  the  neurones  to  which  they  be- 


180 

long,  but  we  have  every  reason  to  believe  that  they  would 
undergo  speedy  and  complete    degeneration." 

Barker  then  views  and  discusses  another  aspect  of  this 
interesting  subject.  Viewing  now  the  question  from  the 
other  side,  he  says:  "The  study  of  portions  of  the  nervous 
systems  from  individuals  who  had  died,  a  certain  length  of 
time  alter  amputation  of  an  extremity,  soon  afforded  data 
which  apparently  stood  in  direct  contradiction  to  the  doc- 
trine of  the  trophic  centres  as  formulated  by  Waller.  For, 
while  Waller  demonstrated  the  complete  degeneration  of  the 
portion  of  the  nerve  fibre  disconnected  with  the  trophic  cen- 
tre, he  maintained  the  integrity  of  that  portion  of  the  fibre 
left  in  connection  with  it. 

"As  early  as  1829  Berard  had  noticed  that  in  the 
spinal  nerves  supplying  a  limb  amputated  some  time  be- 
fore, there  was,  at  autopsy,  distinct  atrophy  of  the  ventral 
roots.  Vulpian,  Cruveilhier,  Hayem  and  Gilbert,  Dickinson, 
Friedla^nder  and  Krause,  Homen,  Vanlair,  Grigorieff,  and  many 
other  investigators  busied  themselves  with  the  subject,  and 
came  to  conclusions  which  were  often  at  variance,  owing,  as 
has  been  shown  by  Marinesco,  to  the  fact  that  the  authors 
studied  and  described  different  phases  of  the  alterations. 
Marinesco  convinced  himself  that  after  amputation  of  a 
limb,  or  after  section  of  a  peripheral  nerve,  there  occur  in 
the  central  part  definite  pathological  changes,  the  intensity 
of  which  depends  upon  the  species,  and  especially  upon  the 
age  of  the  animal  and  upon  the  length  of  time  intervening 
between  the  injury  and  death.  The  younger  the  individual 
at  the  time  of  amputation  and  the  longer  the  time  elapsing 
between  the  operation  and  death,  the  more  marked  are  the 
alterations.  The  degeneration  in  the  central  stump  of  the 
divided  nerve,  although  it  appears  much  later  than 
that     in     the     distal     portion,     presents      similar     morpho- 


181 

logical  appearances  and  is  apparently  an  analogous 
process,  although" — and  herein,  thinks  Barker,  lies  the 
vulnerable  point  of  the  Wallerian  doctrine — "the  central  end 
still  maintains  its  continuity  with  the  'trophic  centre.' 
Not  only  do  the  sensory  fibres  distal  from  the  spinal 
ganglia  degenerate,  but  after  a  time  large  numbers  of  fibers 
in  the  dorsal  roots  proximal  to  the  ganglia  and  their  cor- 
responding fibres  with  their  collaterals  and  terminals  in  the 
dorsal  funiculi  of  the  cord  undergo  pathological  changes  and 
totally  disappear.  The  motor  fibres  of  the  central  stump 
gradually  diminish  in  number;  in  some  instances  they  ap- 
pear to  vanish  almost  totally,  and  a  large  number  of  the 
motor  cells  of  the  ventral  horns  dwindle  in  size  and  may 
after  a  time  be  actually  lost.  The  spinal  ganglion 
cells  do  not  show  gross  alterations  for  some  time  after  both 
peripheral  or  distal  fibres  have  degenerated  (Friedlander  and 
Krause,  Homen,  Vanlair,  Mannesco),  a  finding  which  denotes 
that  their  trophic  mechanisms  differ  in  some  way  from 
those  which  are  concerned  in  the  nutrition  of  the  cells  of 
the  ventral  horns.  I  have  thought  that  this  may  depend 
upon  the  possession  by  the  spinal  ganglion  cells  of  a  cel- 
lular capsule,"  concludes  Barker. 

Another  point  is  to  be  remembered,  he  thinks,  in  ex- 
plaining "the  difference  in  effect  of  division  upon  the  peri- 
pheral motor  and  sensory  nerves  is  the  fact  that,  if  current 
ideas  of  conduction  are  correct,  on  section  of  a  motor  fibre, 
it  is  perhaps  the  discharge  of  impulses  which  is  prevented, 
while  in  the  case  of  the  sensory  fibre  it  is  at  first  the  re- 
ception of  impulses  which  is  interfered  with.  It  must  not 
be  forgotten,  however,  that  even  when  a  peripheral  sensory 
nerve  has  been  cut  through,  the  corresponding  cells  in  the 
spinal  ganglia  may  yet  perhaps  receive  some  centripetal  im- 
pulses from  the  viscera  through  the  rami    communicantes." 


182 

The  life  prolonged  of  the  central  neurones  with  peri- 
pheral sensory  connections  depends,  in  great  measure,  on 
the  continuance  of  normal  peripheral  function,  sending  up  to 
these  centers  those  normal  irritations  which  keep  up  the  cen- 
tral neurone  life — "uibi  irritaiio  ibi  fluxus  nutrieus."  With- 
out this  healthy  excitation  which  conditions  healthy  neurone 
nutrition  and  permits  and  causes  neuratOny  and  neuratrophy 
to  set  in,  the  nerve  center  must  degenerate.  This  seems  to 
me  to  be  a  more  rational  explanation  than  the  conjectural 
possession  of  a  spinal  ganglion  cellular  capsule. 

It  would  be  interesting  to  note,  as  this  author  says  fur- 
ther on  the  subject,  "that  if  the  sympathetic  ganglion  cells, 
which  are  also  encapsulated,  act  similarly  and  preserve  their 
gross  integrity  after  section  of  the  nerve  fibres  belonging  to 
them."  He  refers  to  gross  integrity  alone,  inasmuch  as 
there  is  much  evidence,  some  of  very  recent  date,  from 
which  we  are  compelled  to  believe,  he  says,  "that  the  finer 
structure  of  the  nerve  cell  is  always  altered  by  the 
cutting  through  of  its   axone." 


CHAPTER    XVIII. 

THE  EVOLUTION  OF  THE  NEURAXIS. 


NATURE'S    BUILDING    OF  THE   BRAIN    AND    SPINAL   CORD. 

I  am  not  the  first  teacher  in  a  medical  school  to  make 
the  observation  that  the  study  of  anatomy  and  physiology  of 
the  brain,  spinal  cord,  and  connected  nervous  system  is  not 
generally  pursued  with  that  intensity  of  interest  which  its 
importance  deserves,  by  the  majority  of  medical  students. 
Students  of  medicine  seem  inclined  to  ignore  the  minute 
study  of  the  neuraxis,  as  many  of  them  also  seek  to  avoid 
as  much  as  they  can,  the  details  of  chemical  and  biological 
study,  but  the  successful  treatment  of  the  nervous  system 
demands  of  them  a  thorough  knowledge  of  the  exact  rela- 
tions between  nervous  function  and  structure  in  health  for 
proper  comparison  with  the  changed  nervous  manifestations 
of  disease.  Beginning  with  the  brain,  that  great  English 
Corypheus  of  modern  histological  cerebro  anatomy,  Samuel 
Solly,  who,  following  Tiedemann,  the  great  German  Vesalius 
of  neuro-anatomy,  in  his  day,  also  sought  to  impress  upon  the 
medical  world  many  years  ago,  when  biology  was  yet  young, 
the  fact  that  the  only  philosophical  method  of  simplifying  and 
giving  interest  to  the  anatomy  of  the  human  brain,  is  by 
commencing  with  the  structure  and  functions  of  a  nervous 
system  in  the  lowest  and  simplest    forms    of    animal  exist- 

[133]. 


184 

ence,  and  from  this  rise  by  degrees  to  the  highest,  care- 
fully observing  each  addition  or  part  and  the  relationship 
borne  by  these  to  an  addition  of  function.  "By  pursuing 
this  course  we  shall  be  rewarded  by  finding  that  the  en- 
kepalon,"  Solly  said,  "this  apparently  most  complicated  organ 
in  the  human  being,  is  but  a  gradual  development  from  an 
extremely  simple  fundamental  type  on  one  uniform  and 
harmonious  plan  and  that  the  seeming  complexity  of  the 
cerebro-spinal  axis  in  man  really  arises  from  the  great 
concentration,  as  opposed  to  extreme  diffusion  of  its  com- 
ponent parts  in  the  lower  order  of  animals;  for  in  no  par- 
ticular are  the  higher  orders  more  strikingly  distinguished 
from  the  lower  than  in  concentration  of  function  within 
circumscribed  spaces."  As  we  proceed  in  our  studies  we 
shall,  by  the  aid  of  this  early  master  cerebro- anatomist 
and  the  help  of  other  and  later  eminent  teachers,  see  how 
important  it  is  to  look  below  us  in  the  animal  scale  in 
order  to  clearly  comprehend  man  at  the  top. 

The  study  of  comparative  embryology  in  this  way  has 
not  only  contributed  largely  to  our  knowledge  of  the  cerebro- 
spinal axis,  but  the  highest  interest  of  embryology  centers 
in  the  light  which  this  study  has  thrown  on  the  nature  and 
evolution  of  the  entire  human  nervous  system,  in  which 
this  chair  as  teacher,  and  you  as  learners,  are  so  intently 
and  specially  interested. 

As  the  chief  aim  of  your  life  will  be  to  care  for  the 
brain,  spinal  cord  and  allied  peripheral  system,  including 
the  sympathetic  and  the  organs  of  the  body  governed  by 
and  influencing  this  nervous  system,  it  is  proper  that 
you  should  have,  at  least,  an  outline  idea  of  its  embryonic 
birth  and  development.  By  knowing  something  of  its  evo- 
lution you  will  be  better  qualified  to  delay  or  prevent  that 
premature  involution  which  morbid  processes    tend  to  bring 


185 

about  and  may  be,  to  delay  the    ordinary  involution  of  age 
and  promote  longevity. 

The  human  embryonic  nervous  system  starts  its 
life  from  a  small  beginning,  a  protoplasmic  vesicle 
born  of  the  union  of  an  ovum  and  a  spermatozoon.  In 
the  beginning  a  spot  of  protoplasm  merging  into  a  streak 
of  epiblast  called  the  medullary  plate  and  developing  first 
into  an  elongated  neural  tube  larger  at  one  end,  (the  an- 
terior) than  the  other,  from  which  are  evolved  the  different 
antero-posterior  segments  of  the  brain  described  by  neuro- 
anatomists,  and  from  the  lower  end  of  this  tube  develops 
the  spinal  cord.  Of  man's  origin  as  the  poet  has  said 
of  man's  entire  life,  it  may  be  said, — his  time  is  but  "a 
moment  and  a  point  his  space." 


fig.  93. 


Cells  of  discus  proligerus. 


rammatic— /,  secondary  uucleoli. 


— Portion  of  o\nm 
extruding  a  polar  body, 
and  showing  a  spindle 
and  diaster.  The  iunec 
star  surrounds  the  female 
pronucleus,  the  outer  is 
beneath  the  polar  body. 
The  male  pronucleus  is 
close  to  the  female. 


186 

A   PROTOPLASMIC   VESICLE    BORN    OF  AN  OVUM  AND  A  SPERMATOZOON 

FIG.   94. 


fVv.wv.'vCWtt  3Vve<x\i  av)  XT\c&- 


— /.,  Primitive  streak;  //..  primr- 
tive  streak  and  medullary  groove;  ///., 
later  stage  with  medullary  groovo 
alone;  i\,  first  protovci'tcbra. 


FIG.  95. 


— The  epiblaat  involuted  to  form  the  central  nervous  system  while  still  a> 
single  layer,  rabbit  (after  His).  A  round  eerm-cell  lies  between  the 
proximal  ends  of  two  supporting  cells.   O  b«,x  s\e.>.o.e  v. 


The  accompanying  diagram,  much  like  one  of  Kollman 
of  Jena,  which  I  have  taken  from  MacAlister's  Anatomy, 
and  the  embryonic  sections  following  it,  will  serve  to 
show  us  how  small  and  simple  are  the  beginnings  of  neural 
life  and  to  cause  us  to  marvel  at  the  mysteriously  and 
wondrously  wrought  nervous  mechanism  of  man  and  the 
lower  vertebrata. 


187 


THE  GERMINAL  TUBE  OF  THE   EMBRYONIC   NEURAXIS. 
FIG.  96.  FIG.  97. 

7k 

I 

\^A  hi 


MA  — 


-Mr- 


—  Uw- 


-Diagram  of  anterior  end  of 
nearal  canal — All,  optic  vesicle; 
H,  heart;  Mh,  wall  of  mid-brain; 
Vom,  omphalomesenteric  vein;  Uw, 
protovertebrre. 


— Section  of  embryo,  showing  formation 
of  vertebral  body  around  the  notochord — csp, 
spinal  canal ;  vsp,  spinal  nerve  ;  v:h,  body  of 
vertebra  forming  around  (ch)  the  notochord ; 
mp,  muscle  plate ;  a,  aorta ;  p,  coelom ;  bw, 
somatopleure. 


The  germinal  embryonic  tube  of  the  neuraxis  closes 
interiorly  in  the  process  of  development.  It  then  swells 
first  into  the  three  and  later  into  four  and  finally  into  five 
vesicular  centers  located  one  after  or  below  the  other.  The 
first  three  divisions  constitute  the  anterior,  middle  and  pos- 
terior germinal  cerebral  vesicles.  The  anterior  cerebral  vesicle 
is  then  soon  divided  by  the  development  of  the  falx  cer- 
ebri growing  out  of  what  is  called  the  secondary  vesicle  of 
the  fore- brain,  which  is  the  beginning  of  the  division  of 
the  anterior  cerebrum  into  its  two  hemispheres.  The  falx 
cerebri  being  the  product  of  the  secondary  vesicle  of  the 
fore-brain  does  not  descend  into  and  bisect  the  other  ves- 
icles in  their  evolution,  but  stops  above  the  corpus  callosum, 
basal  ganglia  and  the  other  more  posterior  and  lower  or 
basal  divisions  of  the  brain. 


188 

The  cerebrum  and  cortex,  caudate  and  lenticular  nuclei 
(these  two  latter  being  cortex  formations)  with  the  fornix 
and  corpus  callosum,  are  developed  from  the  secondary 
anterior  cerebral  vesicle.  This  forms  the  anterior  or  fore- 
brain,  prosencephalon  or  telencephalon  as  it  is  variously 
termed. 

The  primary  cerebral  vesicle  (Vh)  makes  the  tween  - 
brain  including  the  optic  thalami  and  commissure,  corpora 
albicantia  and  infundibulum.  The  secondary  vesicle  having 
evwlved  out  of  the  primary  cerebral  vesicle. 

The  mid -brain  (and  this  is  an  unfortunately  confusing 
term  as  distinguished  from  the  tween- brain)  is  formed  from 
the  middle  vesicle  (Mh)  and  includes  the  corpora  quad- 
rigemina  and  peduncles  or  crura  or  legs  of  the  cerebrum. 
Mid  and  tween  are  so  near  alike  in  meaning  that  it  might 
have  been  well  to  have  included  the  near  enough  related 
parts  which  make  up  these  two  divisions  under  one  com- 
mon designation  viz.,  the  quadrigeminal  bodies  and  crura. 
The  fewer  and  simpler  these  divisions  the  better,  but  as  I 
did  not  make  them  1  make  no  further  apologies. 

The  mid  brain  Hh.,  is  made  up  of  the  cerebellum  its 
peduncles  and  the  pons  Varolii.  It  is  developed  from  the 
anterior  of  the  two  under  or  lower  vesicles,  Hh.  Last  of 
all  comes  the  after  brain  and  this  is  an  ill  chosen  designa- 
tion to  distinguish  it  from  the  hind  brain,  hind  and  after 
being  so  nearly  synonymous.  But  it  is  the  language  of 
neuraxis  embryological  evolution  and  we  must  accept  it  as 
faithful  followers  of  the  Masters.  Fortunately  its  meaning 
is  easy  to  remember.  The  after  brain  is  made  up  of  the 
medulla  oblongata  alone  and  is  developed  from  the  posterior 
(Nh,)   of  the  two  under  germinal  cerebral  vesicles. 

Brain  structures  are  also  divided  into  brain  mantle  and 
brain  stem  or  caudex.       All    structures    developed  from  the 


189 

secondary  vesicle  are  included  in  the  brain  mantle.  The 
structures  formed  from  the  remaining  vesicles,  excluding 
the  cerebellum,  constitute  the  brain  stem  or  caudex.  The 
mantle  or  cortex  structure  of  the  brain  envelops  the  most 
of  the  surface  of  its  three  primary  vesicles  after  they  have 
evoluted  into  brain  structures.  Mantle  and  cortex  meaning 
respectively  covering  and  rind,  the  latter  the  same  thing 
only  more  closely  fitting. 

The  germinal  vesicle  cavities  evolute  into  ventricles  and 
aqueducts  or  canals.  Thus,  that  of  the  cavities  of  the  sec- 
ondary forebrain  evolves  into  the  lateral  ventricles,  that  of  the 
primary  forebrain  (Vh)  before  division  and  the  hind  brain  re- 
spectively, furnish  the  third  and  fourth  ventricles  and  spinal 
canal,  while  the  mid-brain  germinal  vesicle  cavity  makes  the 
aqueduct  of  Silvius  which  connects  these  ventricles.  Lower 
down  the  germinal  tube  in  the  diagram  (Mr)  is  the  cavity 
of  the  central  canal.  The  vesicle  cavities  become  the  per- 
manent brain  ventricles  and  the  foramen  of  Monroe. 


FIG. 


—Vertical  longitudinal  section  of  brain  of  human  embryo  of  fourteen  weeks.  1x3. 
(After  Sharpey-  and  Reichert.)  c,  cerebral  hemisphere  ;  cc,  corpus  callosum  beginning  to 
pass  back  ;  /;  foramen  of  Munr.o  ;  p.  membrane  over  third  ventricle  and  the  pineal  bod}' ; 
th.  thalamus ;  3,  third  ventricle  ;  /,  olfactory  bulb  ;  eq,  corpora  quadrigemina  :  cr%  crura 
cerebri,  and  above  them,  aqueduct  of  Sylvius,  still  wide  :  c\  cerebellum,  and  below  it  the 
fourth  ventricle  ;  pv,  pons  Varolii ;  m,  medulla  oblongata. 


The  frogs  of  the  bogs,  the  crocodiles  of  the  Nile  and 
alligators  of  the  Mississippi,  the  codfish  and  whales  of  the  sea, 
the  giants  and  dwarfs  of  the  jungles  and  forests,  the  lizards 


190 

and  toads  and  reptiles  oi  the  fields  and  the  fowls  of  the  air  as 
well  as  those  anthropoid  apes  which  make  Darwin's  con- 
necting link  in  animated  nature  with    man,   have  helped  us 

to  know  our  brain  and  other  portions  of  our  neuraxis. 

Man's  nervous  system  begins  also  with  the  outer  of 
the  three  vesicle  layers  of  the  primitive  embryo  viz. — in 
the  epiblast  as  we  have  said,  which  gives  origin  to  the 
nervous  system  along  with  the  intimately  connected  epi- 
dermis, with  its  hair,  nails  and  glands  and  the  mucous  mem- 
branes of  mouth,  pharynx,  anus  and  the  perceptive  surfaces 
of  the  special  sense  organs.  This  is  also  called  the  neuro- 
blast, vevpov,  a  nerve  and  /JAuo-tos,  a  bud,  because  the  neuroblast 
is  the  bud  of  and  evolves  into  the  nervous  system. 

The  mesoblast  is  also  important  as  it  gives  rise  to  the 
neuroglia,  the  derma  and  connecting  tissues  generally,  the 
serous  and  mucous  wall  linings  of  the  bodies,  cavities  and 
vascular  system,  the  non  nervous  internal  genital  system, 
the  muscles,  bones  and  bodily  excretory  organs.  And  we 
note  here  that  a  division  begins  with  the  very  beginning 
of  organic  life.  The  germinal  vesicles  are  assigned  spec- 
ialties of  work  in  the  animal  economy  from  the  start  and 
the  evolved  organs  keep  up  the  work  to  the  finish  of  ex- 
istence. The  mesoblast  is  the  middle  and  the  hypoblast  the 
innermost  layer  of  the  primitive  embryonic  growth. 

Von  Mihalkovics  has  given  to  embryological  science  a 
microscopic  section  of  the  brain  and  medulla  of  a  chicken 
four  and  a  half  days  old,  which  Edinger  and  other  delineators 
of  the  embryonic  central  nervous  system  have  reproduced.  It 
shows  the  five  brain  vesicles  fairly  well  developed,  so  well 
by  comparison  with  the  much  further  advanced  human 
foetus,  as  for  example  that  of  His  at  about  four  weeks,* 
that  it  may  be    preferably    used    for    our  instruction  today. 


*See  Duane's  Dictionary,  Plate  iv. 


191 

Look  on  this  embryo  chick  and  upon  the  other  illus- 
tration and  delineations  of  man's  evolution  in  the  depart- 
ment of  embryology  and  note  how  man  is  inexorably 
chained  to  nature  in  his  evolution  and  environment,  and 
realize  how  important  it  is    for    you    to    keep    close  to  the 

FIG.  99. 


Commtss.post. 


Vierhugel. 


Hupophysenanlatje 


■e&eHurrji 


Longitudinal  section  through  the  head  of  an  embryo  chick  of  4J<  davs.  The  five  brain- 
vesicles  are  pretty  clearly  marked.  In  the  roof  of  the  inter-brain  is  a  fold  which  later  on 
becomes  the  pineal  gland.  The  epithelium  of  the  pharynx  is  being  pushed  up  toward 
the  b;ise  of  the  brain,  and  is  the  tirst  rudiment  of  a  portion  of  the  hypophysis.  (After 
Mihalkovics.) 


Hinterhirrihbhle,  Hind-brain  cavity. 
llifpiipliynentinluge.  Rudiment  of  hypophysis. 
Mitlelhirnhohle  (aquvuduct),  Mid-brain  cavity 


Nacliliirnhohle,  After-brain  cavity. 
Vierhui/el,  Corpora  iniadrigemina. 


Vorderhirnlcohle,  Fore-brain  cavity. 
Zioiachenhirnhohle,  Inter-brain  cavity.      (J5><i'\.  <vci^.-«) 


revelations  of  nature  in  your  study  and  work  and  give  heed 
unto  her  instruction.  She  speaks  a  forceful  and  unerring, 
though  silent  language  for  your  guidance. 

The  prolongation  of  the  spinal    cord  within    the  cranial 


192 

cavity,  though  classed  vvitli  the  brain,  is  called  the  medulla 
oblongata.  It  is  distinguished  from  the  cord  below  by  its 
form  and  by  the  arrangement  of  its  gray  and  white  matter. 
Its  form  and  relations  give  it  its  name,  oblong  medulla. 
The  gray  substance  of  the  cord  on  each  side  expands  into 
anterior  and  posterior  horns,  but  recedes  backward  in  the 
medulla  oblongata  and  expands  into  a  continuous  layer 
posteriorly.  The  posterior  columns  of  the  spinal  cord  at 
the  top  of  the  cord  are  made  up  of  white  matter  and  di- 
verge into  an  acute  angle  forming  the  restiform  bodies 
and  making  postero-lateral  walls  for  the  fourth  ventricle 
located  between  them.  The  restiform  bodies  continue  into 
and  become  a  part  of  the  inferior  peduncles  of  the  cere- 
bellum. 

In  front,  the  medulla  has  two  longitudinal  elevations 
of  white  matter  on  each  side  of  the  median  line.  These 
are  the  anterior  pyramids  which  are  continuations  of  and 
bulbus-like  enlargements  of  the  anterior  columns  of  the 
cord.  At  their  lower  portions  they  exhibit  a  decussation  or 
crossing  formed  by  oblique  bundles  or  fibers  crossing  the 
median  line  from  below  upward  to  opposite  sides.  The 
right  anterior  pyramid  fibers  come  from  the  left  side  of  the 
cord  and  the  left  anterior  pyramid  fibers  cross  over  from 
the  right  side  of  the  cord.  This  arrangement  forms  the 
often  spoken  of  and  written  about  pyramidal  decussation  in 
the  motor  tract  or  pyramidal  tract  of  the  cord. 

Immediately  outside  each  pyramid  and  almost  adjoining 
it  on  either  side  is  the  elongated  olive  shaped  olivary 
body  called  the  corpus  olivaria,  consisting  externally  of 
white  substance,  but  internally  of  a  thin  convoluted  hiyer 
of  gray  matter,  resembling  in  miniature  the  convolution  of 
a  hemisphere.  They  are  centers  of  gray  substance  in 
the  medulla    oblongata,  super-added    to    the    rest,  and  not 


193 

continuous  with  that  of  the  spinal  cord.  They  have  an  in- 
dividuality and  separate,  though  joined,  existence,  to  the 
cord,  like  a  neurone  of  the  brain  cortex. 

At  the  upper  limit  of  the  medulla  oblongata  is  the 
tuber  annulare,  so  called  because  it  forms  a  ring- like  pro- 
tuberance at  the  base  of  the  brain,  also  called  the  pons 
Varolii  because  it  bridges  over  the  crura  cerebri  and  named 
after  Varolius,  who  discovered  it.  Superficially  it  consists  of 
transverse  bundles  of  fibers  passing  over,  in  an  arched 
form,  from  one  side  to  another  of  the  cerebellum.  Strictly 
speaking  it  is  only  fibers  of  the  tuber  annulare  that  con- 
stitute the  "pons  Varolii,"  but  the  entire  tuber  annulare  is 
most  frequently  designated  as  the  pons. 

This  life  in  the  human  organism,  as  in  all  other  an- 
imal life,  begins  with  the  protoplasmic  cells.  The  neurone, 
with  its  appurtenances,  the  neuraxone,  axone,  neurite  or 
axis  cylinder  process  and  its  dendritic  proliferations,  is  the 
unit  of  human  anatomy.  These  cells  perverted  in  structure 
and  function  are  the  foundation  of  pathology,  the  cellular 
pathology  of  the  great  Virchow.  These  cells  undergo  mul- 
tiplication and  obscure  complex  transformation  whose  pre- 
cise manner  of  change  and  aggregation  into  organism  is  as 
yet  somewhat  beyond  the  ken  of  science.  We  will  not 
inquire  more  minutely  into  the  peculiarities  of  individual 
cell  development,  though  with  all  of  its  obscurity,  it  is  an 
interesting  phase  of  cytology.  Hence  we  begin  our  de- 
scription today  with  the  initial  organic  beginnings  of  life, 
viz. :  the  blended  ovum  and  spermatic  vesicle,  and  from  all 
that  we  have  seen  or  may  see  from  our  glimpses  thus  far 
of  cytology  and  embryology,  we  have  derived  instructive 
confirmation  of  the  old  maxim,  omne  vivum  ex  ovo. 

The  teachings  of  Nature  do  not  confirm  the  fiat  of 
spontaneous  generation. 


194 

There  was  once  upon  a  time  a  divinity  student  ex- 
amined on  the  subject  of  creation  and,  when  he  was  asked  the 
question,  quid  est  crerare?  he  answered,  ex  niJiilo  facere. 
To  this  the  inquisitive  Professor  responded,  ergo  te  doctorem 
faciamus.  This  was  nearer  to  spontaneous  generation  than 
science  carries  us  and  a  medical  doctor  could  not  be  made 
that  way.     He  was  a  divinity  student. 

From  this  consideration  of  man's  origin  embryologically 
we  may  be  prompted  to  ask  with  the  poet,  "Why  should 
the  spirit  of  mortal  be  proud?"  for  he  begins  in  a  spot 
and  a  streak,  a  primitive  streak  and  a  medullary  groove; 
"his  time  a  moment,  and  a  point  his  space." 

His  life  begins  in  a  microscopic  germinal  nucleus  or 
vesicle,  this  nucleus  consisting  of  a  homogeneous  mem- 
brane enclosing  a  network  of  protoplasm  called  nucleoplasm 
and  this  nucleoplasm  is  itself  made  up  of  infinitesimal  pro- 
toplasmic threads  or  filaments  of  exceedingly  complex  or- 
ganism whose  composition  consists  of  many  thousands  of 
molecules,  computed  at  near  half  a  million. 

Here  is  a  drawing  of  the  human  ovum  and  germinal 
vesicle  from  Macalister's  Anatomy.  (See  second  illustration 
in  this  chapter.) 

Two  faint  ridges  called  medullary  folds  {lamina:  dor- 
sales)  appear  in  front  of  the  primitive  groove,  on  eash  side 
of  the  middle  line.  The  furrow  between  them  is  called 
the  medullary  groove  {R) ,  and  is  floored  by  a  streak  of 
epiblast  called  the  medullary  plate.  The  medullary  folds 
unite  in  front  of  the  medullary  plate,  at  the  anterior  end 
of  the  embryonic  area  and,  as  in-  the  course  of  growth 
they  gradually  extend  backwards,  they  push  the  primitive 
groove  to  the  hinder  end  of  the  area,  where  it  finally  dis- 
appears (///). 

Coincidently  with  the  formation  of  the  primitive  groove, 


195 

an  intermediate  series  of  embryonic    cells    appears  between 
the  epiblast  and  the  hypoblast. 

The  embryo  (Figs.  96  and  97)  is  composed  of  thirty  or 
forty  segments,  which  begin  to  appear  shortly  after  embry- 
onic life  commences.  The  metameres  or  somites  are  ventral 
and  dorsal.  Each  ventral  metamere  unites  in  the  process 
of  development  with  another  ventral  metamere  or  embryonic 
segment  to  form  the  cavities.  The  dorsal  metameres  unite 
with  each  other  to  form  the  other  parts,  viz. :  the  myotomes 
or  muscle  segments,  the  sclerotomes,  or  bone  segments  and 
other  hard  tissues,  and  neurotomes  or  nerve  segments,  etc. 

The  segmentation  of  the  germinal  tube  may  be  seen 
forming  into  metameres  (commencing  metamerism)  and 
these  metameres  beginning  to  form  myotone,  sclerotone 
and  neurotone  in  Figs.  96  and  97. 

An  outline  of  the  five  primitive  vesicles  appears  in  Fig. 
96,  and  the  metameres  are  seen  in  process  of  evolution. 

The  notochord,  esp  in  Fig.  97,  (vcotos,  the  back,  plus 
X°p&7,  string,)  is  the  chorda?  spinalis,  or  primitive  back- 
bone—  a  fibro-cellular  or  cartilaginous  rod -like  structure 
which  is  later  developed  into  vertebrae,  as  the  basis  of  the 
future  spinal  column  and  about  which  the  bodies  of  the 
future  vertebrae  are  formed.  It  is  one  of  the  earliest  em- 
bryonic structures  and  persists  throughout  life  in  many  of 
the  vertebrates,  which  are  on  this  account  called  notochordal. 
It  is  the  embryonic  canal  developed  from  the  cells  of  the 
mesoblast  lying  in  close  proximity,  in  the  illustration,  to 
the  later  evolved  spinal  cord. 

It  is  later  on  in  the  process  of  embryonic  development, 
absorbed  and  replaced  by  spinal  column  which  in  man  is 
always  bony,  though  in  some  of  the  lower  animal  species  it  is 
cartilaginous.  The  soft  pulpy  substance  which  filks  the 
cupped  ends  of  the  fishes'  vertebrae  is  notochord  remnant." 


CHAPTER    XIX. 

Till:   EVOLUTION   OF  THE   BRAIN   AND  SPINAL  CORD  OR  NEURAXIS 
(CONTINUED). 


OBERSTEINER'S   DIAGRAM  OF  THE  CEREBRAL  VESICLES. 

FIG.    100. 

7ns 


S  Vh,  Secondary  fore-brain  ; 
Zh,  'tween- brain ;  Mh,  mid- 
brain ;  ///(,  hind-brain ;  Nh, 
after-brain  ;  ms,  longitudinal 
fissure;  FM,  foramen  of  Monro; 
MR,  central  canal. 

A  brain  and  spinal  cord  (neuraxis)  belong  to  all  of  the 
vertebrates.  The  fore- brain,  or  prosencephalon,  is  the  largest 
part  of  the  human  brain.  The  relative  size  of  this  portion 
of  the  brain  to  other  divisions  of  the  brain,  diminishes  as 
we  go  down  the    scale  of  animal  existence.     The   brain,  as 

[196] 


197 

we  see,  is  evolved  from  a  primary  medullary  tube  sprung  from 
a  primary  vesicle.  The  prosencephalon  is  evolved  from  a 
secondary  offshoot  vesicle  from  this  primary  one.  Meynert 
says  these  vesicles  spring  from  and  are  "secondary  sub- 
ordinate appendices  of  the  primary  vesicle."  They  are 
"systematically  disposed  and  lie  on  each  side  of  the  median 
axis  of  the  primitive  brain  structure." 

And  1  must  here  draw  upon  this  and  other  distinguished 
investigators  in   cerebro-histology  for  illustration.     The  first 


fig.  101. 


FIG.   102. 


V.  Prosencepha- 
lon (f  o  re-brai  n  : 
V  o  rder  hir  ii).  Z. 
Thalamencephalon 
(  Tween-brain ;  Zxvis- 
chenhirn).  F.  Fora- 
men between  median 
and  r.  lateral  ventri- 
cle. M.  Mesenceph- 
alon (M  id-b  ra i n  : 
Mil/elhim).  H.  Ep- 
encephalon.  (Hind- 
biain  /-/inter /urn.) 
N  Metencephnlon. 
(After-brain;  Nnchh- 
irn.)      (Reicliert.) 


View  of'the  Convex 
Surface  of  a  fcetal 
Brain. 

V."Prosenceph.  S. 
Fossa  Sy  1  vii .  Z. 
Thalamenceph.  M. 
M  esenceph  .  H. 
Epenceph.  N.  Met- 
enceph.  Beneath  the 
frontal  portion  of  the 
prosencephalon  lies 
the  olfactory  lobe. 


one  is  from  Reichert  and  occupies  a  place  on  the  first  page 
of  the  Masterwork  on  Psychiatry  of  Meynert.  Here  it  is 
with  his  description. 

We    distinguish     (Fig.     101)     the    transition    from    the 
spinal  cord  into  the  after- brain  (medulla  oblongata)  ;     next 


198 

the  hind-brain  (H.  cerebellum),  which  the  roof  of  the  fourth 

ventricle  joins  to  the  posterior  wall  of  the  ventricle  of  the 
.liter- brain.  The  mid-brain  {M.  corpora  quadrigemina)  forms 
the  summit  of  this  structure.  A  part  of  the  prosencephala 
vesicle  lies  between  the  mid-brain  and  the  vesicle  of  the 
hemisphere.  The  part  is  termed  the  inter- brain,  and  cor- 
responds to  the  region  of  the  optic  thalamus  (Z).  The 
vesicles  of  the  hemisphere  develop  into  the  fore-brain   (V). 

The  second,  with  description,  is  by  Meynert. 

Referring  to  illustration  (Fig.  102),  Meynert,  the  emi- 
nent psychiatrist  of  Vienna,  whose  treatise  on  psychiatry 
1  cordially  commend  to  your  further  consideration,  asks  the 
student  to  note  how  in  the  fore-brain  the  anterior  and  pos- 
terior horns  of  the  lateral  ventricles  open  widely  into  the 
hollow  of  the  primary  cerebral  vesicle.  At  this  point  the 
median  wall  of  the  prosencephalon  encircles  this  opening. 
The  outer  wall  of  the  prosencephalon  has  given  rise  mid- 
way to  the  fossa  Sylvii.  The  inner  wall  closes  in  upon 
the  cerebral  ventricle.  The  fornix  ascending  from  the 
cornu  ammonis  between  S.  and  Z.,  regions  corresponding  to 
the  corpus  striatum  and  the  thalamus  opticus,  constitutes 
the  posterior  portion  of  the  median  wall.  The  superior 
convex  arch  of  the  fornix  is  flattened  down,  but  the  de- 
scending portion  of  the  fornix  is  enclosed  within  the  front 
wall  of  the  anterior  cerebral  vesicle. 

The  fornix  bounds  the  hollow  separating  the  fore  and 
inter-brain,  which  cavity  is  rendered  cleft-shaped  by  the 
inward  growth  of  the  thalamus,  and  forever  after  remains 
broadest  at  its  interior  end   (foramen  of  Monro). 

The  upper  wall  of  the  thalamencephalon  consists 
simply  of  the  membranous  roof  of  the  third  ventricle,  which 
passes  to  the  edge  of  an  arch-shaped  constriction  arising 
from  the  upper  and  anterior  wall  of    the  thalamencephalon. 


199 

This  constriction  represents  the  fimbra  of  the  fornix.  The 
middle  choroid  plexus  of  the  upper  wall  is  continued 
through  the  foramen  Monroi  into  the  plexus  of  the  lateral 
ventricles.  The  fornix  in  reality  limits  the  extent  of  the 
fore- brain.  As  soon  as  the  septum  and  the  corpus  callosum 
are  developed,  the  gyrus  formcatns  appears  to  be  a  limiting 
formation,  or  at  least  a  secondary  free  margin  of  the  cer- 
ebral cortex.  The  outer  cerebral  wall  growing  from  the 
fossa  Sylvii  toward  the  median  line  gives  rise  to  the 
ganglia  of  the  prosencephalon  and  encroaches  upon  the  an- 
nular opening  in  the  median  wall,  and  thus  fills  in  the 
once  copious  hollow  of  the  ventricle. 

The  prosencephalon  continues  to  extend  in  a  posterior 
direction  at  later  stages  of  development;  we  find,  therefore, 
on  horizontal  sections,  that  the  corpus  striatum  and  thala- 
mus opticus  are  juxtaposed  from  the  outside  inwardly,  in- 
stead of  lying  one  behind  the  other. 

The  succession  of  the  three  cerebral  vesicles  is  marked 
by  several  flexions  on  the  axis  of  the  original  medullary 
tube.  The  cervical  flexure  (convex  posteriorly)  marks  the 
transition  from  the  spinal  cord  to  the  metencephalon ;  the 
frontal  flexure  (convex  anteriorly),  the  transition  from  the 
mesencephalon,  from  which  the  parietal  flexure  is  formed. 
The  chorda  dorsalis  terminates  in  the  sinus  formed  by  the 
last-named  flexure. 

Here  are  yet  further  illustrations  from  other  students  of 
neuro-embryology  and  cerebral  evolution. 

They  must  constitute  for  us  a  lecture  largely  without 
words,  giving  you  a  mere  glimpse  only  of  this  interesting 
subject  for  which  you  have  now  scarcely  more  time.  They 
will  show  you  the  natural  and  normal  conditions  of  brain 
birth  and  evolution  and  fuller  details  may  be  acquired  when 
you  have  more  time  at  your   disposal. 


_>(H) 


FIG.    103. 


Outer  surface  of  human  foetal  hrain  at  six  months,  showing:  origin  of  principal 
fissures  (after  Sharpey  and  K.  Wagner).  F,  frontal  lobe;  P.  parietal;  0.  occipital;  7", 
temporal  ;  n,  n,  a,  faint  appearance  of  several  frontal  convolutions  ;  x.  x,  sylvian  fissure  ; 
s\  anterior  division  of  same  ;  C.  central  lobe  of  island  i>''.  Reil  ;  >',  fissure  of  Kolaudo ;  p,, 
external  perpendicular  fissure. 

'  Upper  surface  of  braiu  Rafter  Sharpey  and  R.  Wagner). 


FIG.   104. 


¥«  6<Sit^r  (Description  mcilfW) 


CX.  OuXttr  <VtpecX^    Jy.  \t\.x\jex'  o-^q.<JC   ^>V\oxyvw<5  \.v\tv«.*\oweT  \jo«. 


201 

The  precise  anatomic  details  and  other  elaborate  de- 
scription are  fully  given  in  the  pages  of  Meynert,  Edinger, 
Foster,  His,  and  other  embryologists,  and  in  your  physiolo- 
gies and  microscopic  anatomies,  but  it  is  obvious  we  can 
not  use  them  all  here  and  now  in  a  single  hour.  The 
diagrams  and  figures  of  His  will  especially  instruct  you  if 
you  have  time  to  study  them. 

Meynert  copies  from  Reichert  this  frontal  aspect  of  a 
fcetal  brain,  with  its  germinal  spots  for  the  prosencephalon 
V,  thalamencephalon  Z,  mesencephalon  M,  and  meten- 
cephalon  N,  "to  show  what  an  insignificant  part  of  the 
original  brain  mass  the  prosencephalon  is." 

fig.  105. 


I/U 

Frontal  As- 
pect of  a  Fcetal 
Brain  ;  after 
Reichert. 

V.  Prosenceph- 
alon. Z  Tha- 
lam  enceph  a- 
lon.  M.  Mesen- 
cephalon. N 
Metencephalon. 

Dr.  Alexander  Hill,  Master  of  Downing  College,  Cam- 
bridge, and  translator  of  Edinger,  an  indispensable  book 
for  your  leisure  hours,  gives  an  interesting  account  of  the 
epiblast,  a  small  part  of  which  we  draw  upon  to  embellish 
this  lecture.  Barker's  chapter  on  the  histogenic  relations 
of  the  neurones  will  still  further  instruct  and  entertain  you 
on  the  theme  of  this  lecture,  as  will  also  His  and  other 
embryological    histologists. 

The  portion  of  the  epiblast  which  is  marked  in  the  illus- 


202 

tration  as  the  seat  of  origin  of  the  central  nervous  system  con- 
stitutes the  floor  and  sides  of  the  medullary  groove.  It  is  not 
simply  a  uniform  plate,  but  the  central  portion,  out  of 
which  the  spinal  cord  will  be  formed,  is  distinct  from  a 
row  of  thickenings  which  lies  on  either  side  of  the  large 
main  fossa.  It  is  these  lateral  thickenings  of  the  epiblast 
which  develop  into  the  spinal  ganglia   (His). 

The  medullary  folds  grow  up  until  meeting  in  the 
mid-dorsal  line,  they  convert  the  medullary  groove  into  a 
canal.  Closure  occurs  in  the  neck-region  first,  and  spreads 
rapidly  forwards  over  the  head  and  more  slowly  backwards 
through  the  dorsal,  lumbar,  and  sacral  regions.  The  rudi- 
ments of  the  sensory  ganglia  (both  cranial  and  spinal)  are 
formed  by  delamination  from  the  lateral  thickenings  just 
described   (Beard). 


fig.  106. 


.-Transverse  sections  through  a  developing  cbick,  showing  the  forma- 
tion ol  the  scifsory  root-ganglia  (after  flcavl). — <7a,  Ganglia;  <)>,  epiblast; 
Ay,  hypoblast;  m.p  medullary  plate:  «,  uutochord :  ntf,  neuroepithelial 
tube;  e.e,  central  canal.    Ob^tsievAe* 


FIG.   107. 


203 


Sul.ch 


.-Nuc.caud. 


W-Pulv. 

--Lat.lem. 


W 


7%. 


**—D.Tn.f. 


,f. 

■P.  sul 


. — Sul.  eft.,  Chorioid  sulcus.  Flic.  ca«d.,  Nucleus  caudatus.  Thai., 
Thalamus.  St.  m.,  Stria  raedullaris.  P.  b.,  Pineal  body.  C.  q..  Corpora 
quadrigemiaa,  Pulv.,  Pulvinar.  Fr.,  Frenulum,  hat.  lem.,  Medial  lemniscus. 
A.  p.  c,  Anterior  peduncle  of  cerebellum.  M.  p.  c,  Middle  peduncle  of  cere- 
bellum. St.  a.,  Acoustic  strias.  C.  r.,  Corpus  restifonne.  C.  tub.,  Cuneate 
tubercle.  F.  G.,  Funiculus  of  Goll.  D.  m.  f.,  Dorsal  median  fissure.  P.  sul., 
Paramedian  sulcus.  L.  tr.,  Lateral  tract.  D.  I.  sul.,  Dorso-lateral  sulcus. 
F.  B.,  Funiculus  of  Burdach.  CI.,  Clava.  Al.  tin.,  Ala  cinerea.  T  h.,  Hypo- 
glossal triangle.  A.  a.,  Acoustic  area.  C.  f.,  Colliculus  facialis.  S..  Urn., 
Sulcus  limitans,  •  E.  m.,  Eminentia  medialis.  V.  V.t  Anterior  medullary1 
velum.  TV,  Trochlear  nerve.  C.  g.  m.,  Medial  geniculate  body.  C.  g.  I* 
Lateral  geniculate  body.  P.  br.,  Posterior  brachium  of  mesencephalon) 
(After  Van  Gehuchten.) 

.^A.-eejS,'^c\j   VYfru^CeWcs-Jfe   Q.*o*oXov^\^  e^  AA<\e  \svoA-c\j 


204 


THE   EVOLUTION  OF  A   Ml  RAXIS. 
FIG.   108. 


V 

;" 

1 

1 

■ 

As  delineated  by  Samuel  Solly,  the  English  Corypheus  of  modern  neuro- 
anatomy. This  illustration  is  not  so  clear  as  we  should  have  been  pleased 
to  have  made  it,  because  of  the  tarnishing  of  the  plate  by  age.  The  work 
is  marvellous,  considering  the  remote  year  in  which  the  work  was  done. 


LATERAL     VIEW     OF     FULLY     EVOLUTED     HUMAN    CEREBRUM,    SHOWING 

CONVOLUTIONS,     FISSURES    AND    ARTERIES. 

(After  Testut.) 

FIG.   109. 

-Or' 


^sJ 


2.  artfre  fror-ialo  ioftriouro.  — 


3,  arte  re  frouullo  ascendamo.  —  i,  artere  panclalo  asceouaato. 


205 

The  sum  of  this  matter  of  the  embryonic  evolution  of 
the  brain,  from  the  three  primary  vesicles  stated  in  an- 
other way,  is  as  follows:  From  the  anterior  vesicle  de- 
velops the  optic  nerve  and  its  retinal  expansion  or  retina 
in  the  posterior  part  of  the  eyeball.  The  anterior  vesicle 
then  undergoes  subdivision  into  the  anterior  and  middle 
vesicle.  From  this  develops  the  prosencephalon  (fore-brain), 
from  which  are  formed  the  cerebral  hemispheres.  Budded 
off  from  the  prosencephalon  are  two  lateral  vesicles, 
the  cavities  which  constitute  the  lateral  ventricles,  cor- 
pora striata,  and  olfactory  lobes  (  rhienocephalon  ) .  "The 
floor  of  the  thalamencephalon  or  diencephalon  (inter-brain) 
forms  the  optic  chiasm  and  infundbulum;  its  walls  the 
optic  thalami;  its  roof  the  pineal  gland,  anterior  and 
posterior  commissures,  velum  interpositum,  and  choroid 
plexus;  and  its  cavity  the  third  ventricle.  The  floor  of  the 
middle  vesicle  (mid-brain,  mesencephalon)  forms  the  crura 
cerebri;  its  roof  the  corpora  quadrigemina;  and  its  cavity 
the  acqueduct  of  Sylvius."  The  posterior  vesicle  divides 
into  two  parts,  an  anterior  (hind-brain,  or  metencephalon, 
the  floor  of  which  develops  into  the  pons  and  the  roof 
of  the  cerebellum;  and  a  posterior  (after-brain)  myelen- 
cephalon  (Wilder)  the  floor  and  sides  of  which  form  the 
medulla,  and  the  cavity  of  the  fourth  ventricle.  {Vide 
Duane.) 


206 

ILLUSTRATION  OF  A  PORTION  OF  UNDER  SURFACE  OF  BRAIN  IN  IMMEDI- 
ATE CONNECTION  WITH,  AND  CONTINUATION  UPWARD  FROM,  THF. 
SPINAL  CORD.  ALL  THE  CRANIAL  NERVES  ARF.  HERE  SHOWN,  VND 
NEARLY  ALL  THF  UPPER  (CRANIAL)  PART  OF  THF  CEREBRO-SP1NAI. 
AXIS.  THE  OPTIC  NERVE  DISTRIBUTORS  DO  NOT  SHOW  NOR  DOES 
ANY  OF  THE  LEFT  HALF  OF  BRAIN  APPEAR  EXCEPT  THE  OPTIC  THAL- 
AMUS, THE  LEFT  CROSS  CEREBRA,  OPTIC  TRACT,  ETC.,  DE- 
SCRIBED UNDER  THE  CUT.  THE  ANTERIOR  UNDER  LOBE  ON  RIGHT 
APPEARS  AS  LIFTED  AND  PRESSED  UP  AND  FATTENED  SOME. 

FIG.   110. 


Superficial  Oric.ins  op  Craw 
I'.  Olfactory  tract 
II     Optic  nerve. 
It'    Optic  tract. 
HI.  Third    or    oculo-motoi 

IV  Fourth  nerve. 
V.  Filth  nerve,  sensory  root 

V  ,   Fifth  nerve,  motor  root 
1,3,3   Main  divisions  of  fifth 

VI  -i Ml,  nerve. 
VII.  Facial  nerve. 
VIII     Auditory  nerve 

IX.  Glossopharyngeal 

X.  Vagus. 
XI    Spinal  accessory 


rl    LU 


brvus  (/rum  Qunin  i  "  Anatcmy"). 

XII.  Hypoglossal.  x    Posterior   perforated 

CI.  First  cervical  nrrve.  space. 

C.   Island  of  Reil.  P    Cerebral  peduncle. 

Th    Optic  thalamus  (the  It-     pv     Pons  Varolii. 

land  of  Keil  having  been     Ce    Cerebellum. 

removed).  [turn      /   Fillet 

I.   Internal  corpus  gemcula-  .  Jl .    Flocculus 
<■     External  geniculalum  />/i    Anterior  pyramid 

h.  P.iu.t.iry  body.  o    Olive 

ic   Tuber  cinereum  d    Anterior  median  fissuri 

n.  One  of  the  corpora  albi-        of  cord."" 

c.-intia.  I  V.  Lateral  tract  of  medulla 

5y.  Sylvian  fissure.  I  .<     Anterior  column. 

»•    Anterior   perforated         i  Ct.  Lateral  column. 

space 


207 


DESCRIPTION  OF  FIG.    108,   PAGE  204. 

The  figures  in  Fig.  108  represent  different  stages  in  the  development  of 
the  human  brain.  The  first  three  of  this  series  exhibit  the  form  of  the  fcetal 
brain  at  seven  weeks,  with  a  side  and  a  posterior  view  of  the  cerebro- 
spinal axis  at  that  early  period. 

Fig.  6  shows  the  amazingly  rapid  progress  which  development  has 
taken  at  the  ninth  week,  while  Figs.  7,  8,  9,  and  10  show  the  brain  of  a 
foetus  of  twelve  weeks  and  point  out  still  more  decidedly  this  steady  ad- 
vancement. 

Fig.  11,  showing  the  brain  of  a  foetus  of  fifteen  weeks,  teaches  us  how 
gradually  this  important  organ  advances  towards  perfection;  and  12,  ex- 
hibiting the  brain  of  a  foetus  of  nearly  five  months,  is  interesting,  as  it 
demonstrates  that  even  at  this  advanced  period  the  brain  is  still  smooth 
like  the  brain  of  a  rodent  animal. 
Fig.  3.     Foetus  of  seven  weeks. 

a.     Projection  of  the  neck. 
Fig.  4.     Brain  and  spinal  marrow  of  the  same  foetus  seen  laterally. 

a.  Spinal  cord. 

b.  Enlargement  of  the  cord. 

c.  Cerebellum. 

d.  Optic  tubercles,  or  quadrigerhinal  bodies. 

e.  Optic  thalami. 

f.  Membraniform  hemispheres  of  the  brain. 

g.  Protuberance  analagous  to  the  corpora  striatum. 

Fig.  5.     Posterior  view  of  the  same  brain,  split  and  open  in  all  its  length. 
a,  a.     Spinal  marrow. 
h.     Orifice  of  the  canal  of  the  spinal  marrow. 

c.  Swelling  of  the  spinal  marrow. 

d.  d.     The  cerebellum  split  in  the  median    line,  and    laid    like  a  bridge 

over  the  fourth  ventricle. 

e.  e.     The  quadrigeminal    bodies    separated    from    one    another  in  the 

median  line. 
Fig.  6.     Brain  of  an  embryo  of  nine  weeks. 

a,  a.     The  two  principal  columns  of  the  spinal  marrow,  separated  from 

one  another  by  a  longitudinal  fissure. 

b,  b.     Cerebellum. 

c     Parts  which  give  rise  to  the  quadrigeminal  bodies. 

d.  Thalami  optici. 

e.  Membranous  hemispheres,  turned  backwards  and  inwards. 


208 

Brain  of  an  embryo  ot  twelve  weeks  seen  in  the  cranium. 
a,  .i.     Fragments  removed  from  the  cranium,  which  has  been  opened. 
/'.     Spinal  marrow. 

S welling  of  the  spinal  marrow,  which  is  bent  inwards. 
./.     Cerebellum. 

f.     Elevation  which  gives  rise  to  the  quadrigeminal  bodies. 
<;.     Cms  cerebri,  or  a  cord  of    the    spinal    marrow   which    comes  down 

again  and  is  directed  forwards. 
//.     Membranous  hemisphere  of    the  cerebrum,  broken  down  behind  and 

betore;  it  does  not  yet  cover  the    eminences    destined    to  form  the 

quadrigeminal  bodies. 
Fig.  8.     Brain  and  spinal  marrow  of  the  same  fietus  seen  posteriorly. 

a.  .;.     Spinal  marrow,  with  its  posterior  longitudinal  fissure. 

b.  Cerebellum,  and  beneath  it  the  fourth  ventricle. 

c.  .'.     Hemispheres  of  the  cerebrum. 

J.     Eminences  which  are  to  become  the    quadrigeminal  tubercles,  with 
the  fissure  which  they  present. 
Fig.  9.     Inferior  surface  of  the  brain  of  the  same  fietus. 

a,  .?.     Spinal  marrow,  with  the  anterior  longitudinal  fissure. 
/>.  b.     Swelling  of  the  spinal  marrow  bent  forward. 

<-.  c.     Peduncles  of  the  cerebellum,  which  arise  from  the  cerebellum. 

./.  </.     Cerebellum. 

<-.  <-.     1'eduncles  of  the  cerebrum, 

/'.     .Wammillary  eminences. 

1'ituitary  gland. 
//,  //.     Anterior  lobes  of  the  cerebrum. 

1.  1.     The  posterior  and  round  appendices    which    represent  the  middle 
and  posterior  lobes. 
Fig.  10.     View  of  the  superior  surface  of  the  brain    of  the  same  foetus;  the 
membranous  hemispheres  are  separated  from  one  another  and  laid  aside. 
.7.  j.     The  two  principal  cords  of  the  spinal  marrow. 

b,  Posterior  longitudinal  fissure. 

c,  c.     Cerebellum. 

J,  <!.     A\asses  which  are  to  form  the  quadrigeminal  bodies. 

t\  <\     Thalami  optici. 

/',  f,  g,  g,  g,  g-     Membranous  hemispheres    separated  from  one  another 
and  laid  on  the  sides. 

//,  //.     The  two  corpora  striata,  which  are  a  little  wider  anteriorly,  and 
divided  into  two  parts  by  a  slight  fissure. 

1.     Commissure  of  the  two  hemispheres    and  commencement  of  the  cor- 
pus callosum. 

k,  h.     Lateral  ventricles,  with  the  radiated  folds    of    the  under-surface 
of  the  hemisoheres. 
Fig.  11.     Superior  surface  of  the  brain  of    a  fietus  fourteen  or  fifteen  weeks 

of  age. 

a,  a.     Spinal  marrow. 


209 

b.  Peduncles  of  the  cerebellum  separated  from  one  another,  from 
above  downwards,  which  brings  the  fourth  ventricle  into  view. 

c.  The  cerebellum,  which  has  not  yet  any  fissures. 

d.  d.     The  right  hemisphere  of  the  cerebrum,  which  does  not  yet  cover 

the  quadrigeminal  mass. 

e.  Sinking  of  the  membranous  hemisphere. 

Fig.  12.     Side  view  of  Hie  brain  of  a  foetus  of  twenty-seven  weeks. 

a.  Spinal  marrow. 

b.  Corpus  restiforme. 

c.  Corpus  pyramidale. 

d.  Corpus  olivare. 

e.  Cerebellum. 

/.     Bending  of  the  spinal  marrow  forwards. 

g.     Cerebellum. 

h.     Annular  protuberance. 

i.     Middle  lobe  of  the  cerebrum. 

k.     Posterior  lobe. 

/.     Ante-rior  lobe. 

m.  in.  The  fissura?  Sylvii  are  very  deep  and  extend  to  a  great  distance 
on  the  sides;  they  lodge  the  middle  cerebral  arteries. 

n.     The  olfactory  nerve,  which  descends  from  the  fissura  Sylvii. 

o,  o,  o.  Depressions  on  the  cerebral  substance,  which  are  a  com- 
mencement of  the  convolutions. 


The  brain  ventricles,  according  to  Walker,  who  made  the  experiment  of 
displacing  their  fluid  with  ventricle  casts,  were  found  to  contain  twenty-six 
cubic  centimeters  of  cerebro-spinal  fluid.  You  can  try  this  experiment  and 
verify  Walker  in  the  dissecting-room.  After  casting  the  ventricles,  put  the 
casts  in  fluid  and  measure  the  amount  they  displace. 

The  gray  matter  of  the  cerebrum,  according  to  Halliburton,*  averages 
81  per  cent  and  the  white  matter  of  the  brain  and  neuraxis  is  70  per  cent. 
So  that  man's  nervous  system  is  mostly  water,  notwithstanding  its  won- 
drous construction. 

From  repeated  experiment  Broca  concluded  that  the  pia  mater  weighed, 
normally,  from  45  to  50  grams  at  ages  averaging  from  twenty  to  sixty.  At 
fifty  its  weight  was  ten  grams,  or  one-sixth  less  than  at  sixty.  At  from 
twenty  to  thirty  it  weighed  fifteen  grams  less,  or  one-fourth  the  weight  of 
the  pia  at  sixty  years  of  age. 

The  records  of  normal  brain  weights  include  the  normally  filled  blood 
and  lymph  vessels,  ventricles  and  membranes  connected  with  the  entire 
encephalon. 

*  Howell's  Text-book  of  Physiology. 


210 


FIG.   111. 


p'vcvovarw  c-^  \V\c  Qvqau   o\eoo.. 


IuT£RBR*tN  OR 
TwiCNI'l-AIN. 


MiU 


.  liarm 

Peduncu. 


> 


Hi 

HlNDSRAIM 


AT1  V 
Str 

AFTSRBRAIN. 


ZpiuauCobd, 


MeisEnhat^. 


Hie  brain-structures  from  the  thalamus  to  the  -].in;il  cord   (the 
brain  item").     The  cerebellum   divided^  and   removed   on    the   left. 


Practically  the  brain  mantle  is  all  of  the  brain  above  this. 


CHAPTER   XX. 

HISTORY    OF    THE    EVOLUTION    OF    THE    BRAIN. 


SOME   FURTHER   FACTS  CONCERNING  THE  BRAIN. 

In  1819,  before  these  plates  were  made,  Arnold,  Reich- 
ert,  Foville,  Burdach  and  others  had  made  important 
contributions  to  embryologic  and  fully  developed  brain 
structure.  Burdach's  book  on  the  life  of  the  brain  was 
published  as  early  as  1819,  and  Reil  had  already,  according 
to  the  testimony  of  Edinger,  practiced  the  hardening  process 
and  discovered  the  corona  radiata,  the  nerve  course  of  the 
tracts  of  the  crura  cerebri  and  their  relation  to  the  corpus 
callosum,  "the  lemniscus  and  its  origin  in  the  corpora 
quadrigemina,  the  lenticular  nucleus,  the  island  of  Reil  and 
many  other  parts." 

In  his  first  lecture  Dr.  Ludwig  Edinger,  of  Frankfort- 
on-the-Main,  gives  an  interesting  resume  of  the  advance 
of  discovery  and  methods  of  study,  bringing  the  record 
of  work  down  to  the  days  of  Ramon  y  Cajal,  Lenhossek, 
Nissl  and  the  other  men  of  mark  in  our  time  in  neuro- 
cytology.  This  is  of  such  interest  that  I  abstract  the  es- 
sential part  of  the  record. 

"Up  to  about  the  middle  of  this  century  the  most 
prominent  methods  of  investigation  were  anatomical  dissec- 
tion with  the  knife  and  teasing  out  fibers  from  hardened 
specimens    of    brain    with    forceps.     By   the    latter    method 

[211] 


212 

Gall,  Burdach,  Reil,  F.  Arnold  and  Foville  discovered  much 
that  was  new.  Vo  Tiedemann  and  Reicherl  is  due  the  chiel 
credit  of  introducing  the  study  of  embryology,  from  which 
\w  have  learned  much  concerning  general  morphological 
conditions. 

In  1833  a  delineation  of  the  brain's  evolution  by  Sam- 
uel Solly,  one  time  Lecturer  on  Anatomy  and  Physiology  in 
St.  Thomas  Hospital,  appeared  in  England,  based  on  his 
own  and  the  researches  ol  Willis  and  Vieus^eus,  (the  latter 
first  having  demonstrated  (in  1864)  the  fibrous  structure  ol 
the  medullary  portion  of  the  brain),  and  those  of  Reil,  Gall, 
Spursheim,  Vicq,  d'Azyr,  Rolando,  Sommering,  Serres, 
Tiedemann,  Sylvius,  Nepper  and  Van  Leuwenhceck,  the  lat- 
ter having  first  instituted  microscopical  examinations  oi  the 
brain. 

*  *  *  About  this  time  Ehrenberg  proved  that  the 
brain  consisted    of    innumerable   microscopic   "tubules." 

Remak  (1838)  had  given  a  more  accurate  description 
of  the  ganglion-cells,  and  Hannover  (1840)  had  shown  their 
connection  with  the  nerve- fibers.  After  this  Edinger  states 
that  "a  simple  process  of  teasing  could  never  give  the  desired 
insight  into  the  structure  and  arrangement  of  the  central  nervous 
system.  To  B.  Stilling  is  due  the  great  credit  of  originating 
and  bringing  into  use  a  new  method,  viz.,  the  preparation 
of  thin  sections,  or    rather,  of  whole  I    sections,  which 

are  made  in  different  but  in  definite  directions  through  the 
organ  to  be  examined.  In  a  foot  note  Edinger  says:  "Thin 
sections  of  the  central  nervous  system  had  been  made  be- 
fore Sti Ming's  time  [e.g.,  B.  Rolando,  1824).  but  the  recon- 
struction of  the  organ  by  the  combination  of  extended 
of  sections  was  first  done  by  Stilling." 
'  The  sections  so  prepared  were  carefully  examined 
throughout,   the  pictures  they  presented  combined,  and  thus 


213 

the  structure  and  arrangement  of  the  central  nervous  sys- 
tem were  determined.  By  means  of  this  method  and  the 
studies  which  he.  instituted  by  its  use,  Stilling  laid  the 
foundation  of  the  modern  anatomy  of  the  spinal  cord,  the 
oblongata,  the  pons  and  the  cerebellum.  On  the  25th  of 
January,  1842,  Stilling  froze  a  piece  of  spinal  cord  at  a 
temperature  of  13°  R.,  and  then,  with  a  scalpel,  made  a 
moderately  thin  cross-section.  'When  I  placed  this  under 
the  microscope,'  he  writes,  'and,  with  a  power  of  15  diam., 
saw  the  beautiful  transverse  striations  (central  nerve- 
tracts),  I  had  found  a  key  which  would  reveal  the  mysteries 
of  the  wonderful  structure  of  the  spinal  cord.  Not  more 
joyfully  did  Archimedes  cry  out,  "Eureka!"  than  1,  at  the 
first  sight  of  these  fibers.'  " 

Stilling's  method  was,  up  to  within  two  decades  ago, 
the  one  most  used  in  investigations  of  the  central  nervous 
system.  "It  is  rendered  very  much  easier  by  the  splendid 
hardening  which  these  organs  undergo  in  dilute  chromic 
acid,  or  in  a  solution  of  chromic  salts, — a  discovery  of 
Hannover    and    Eckhardt. 

"The  sections  are  made  'free-hand,'  with  a  razor,  or, 
better,  with  a  microtome,  which  cuts  much  more  exactly 
and  enables  us  to  make  larger  and  more  even  sections. 
Welcker,  Rivet,  Weigert,  Thoma,  Gudden,  Schiefferdecker, 
and  others  have  been  of  service  in  constructing  microtomes 
adapted  to  the  purpose.  We  can  now  divide  an  entire 
human  brain  into  an  unbroken  series  of  sections,  less 
than  to  millimeter  in  thickness. 

"These  sections  may  be  examined  unstained.  All  that 
Stilling  discovered  was  found  in  such  unstained  sections. 
It  is  better,  however,  to  use  staining  fluids. 

"To  Gerlach  is  due  the  credit  of  first  calling  attention 
(1858)   to  the    advantages   to  be  derived    from    staining   the 


214 

sections  in  carmine.  As  time  passed  on,  many  new  stain- 
ing methods  were  devised,  particularly  with  aniline  colors 
(nigrosine,  etc.). 

"But  it  is  only  very  recently  (1883)  that  we  have 
learned  from  Golgi  a  method  which  brings  out  ganglion- 
cells  more  distinctly  than  the  old  one  of  Gerlach.  This 
method  rests  on  a  production  of  a  deposit  of  silver  salts  in 
the  cells  and  their  processes.  The  course  of  the  fibers  in 
the  central  nervous  system  is  not  made  much  more  distinct 
by  staining  with  carmine.  It  is  possible,  however,  by  a 
method  of  staining  with  hematoxylin  introduced  by  Wei- 
gert  (1884),  to  color  even  the  finest  nerve-fibril  a  deep 
blue-black,  and  so,  making  use  of  Stilling's  method,  it  is 
easy  to  trace  the  course  of  the  fibers  much  farther  than 
was  formerly  possible. 

'  The  stained  sections  are,  in  accordance  with  the 
special  instructions  of  Clark  (1851),  dehydrated  by  placing 
them  in  alcohol,  and  then  cleared  up  in  some  ethereal  oil 
or  xylol.  But  unstained  sections  also  reveal  the  course  of 
the  fibers  if  cleared  up  in  xylol,  as  was  done  by  Henle 
and  Merkel.  This,  however,  does  not  always  succeed. 
Beautiful  pictures  may  be  obtained  by  using  the  gold  stain- 
ing methods  of  (Gerlach,  Flechsig,  Freud,  and  many 
others).  Also,  by  staining  the  nerve-fibers  with  osmic  acid 
(Exner)." 

Stilling's  method  has,  up  to  very  recently,  been  followed 
by  most  of  the  investigators  of  the  latter  half  of  the  nine- 
teenth century,  but  has  been  later  succeeded  by  the  method 
of  Golgi,  of  which  you  are  to  learn  much  as  you  advance  in 
the  study  of  microscopic  neuro-anatomy. 

The  revelations  of  brain  evolution  under  the  difficult 
and  meager  methods  of  investigation  prior  to  the  hardened 
brain  slicings  and  the  advent  of  the  microscope  were  won- 


215 

derful  testimonials,  as  some  of  these  illustrations  show,  to 
the  indefatigable  spirit  of  research  of  our  forefathers  on  the 
field  of  neural  embryology.  But  the  later  sections  and  micro- 
scopic discoveries  of  brain  and  cord  and  nerve,  startle  cre- 
dulity and  almost  surpass  the  bounds  of  possible  belief. 
They  astonish  us  like  the  telegraph  did  our  fathers  and  as 
the  phonograph,  graphophone,  mimeograph  and  marconi- 
gram  surprise  us.  Yet  their  revelations  are  astonishingly 
true.  Science  now  places  its  penetrating  finger  upon  the 
neurones,  whose  dwelling  place  is  at  the  seat  of  perception, 
reflection  and  psycho-motor  function,  as  we  have  already 
seen,  in  our  survey  of  neurological  research  and  as  we  shall 
yet  see  further  in  our  progress  of  discovery  along  the  pathway 
of  the  neuraxis.  Electrical  discovery  too  has  aided  us,  espec- 
ially in  the  direction  of  cerebral  localization,  which  will  en- 
gage our  attention  in  another  lecture.  For  by  its  means, 
with  insulated  electrodes,  Fritsch  and  Hirtzig  proved  the  fo- 
cal electrization  of  the  brain  and  Ferrier,  Horsley  and  their 
followers  have  localized  its  psycho- motor  functions,  most  of 
which  have  been  confirmed  by  demonstration,  pathological 
processes  and  associated  cerebral  symptoms. 

There  are  some  general  facts  concerning  the  brain 
which  may  profitably  be  recounted  here,  before  we  discuss 
the  subject,  as  we  shall,  later  on,  more  specifically. 

BRAIN  SIZE  AND  BRAIN  WEIGHTS  AND  THEIR  RELATION 
TO  MIND  CAPACITY. 

The  aggregate  complexity  of  the  nervous  system  seems 
greatest  in  what  naturalists  call  the  primates,  or  man  and 
apes  and  the  vertebrate  animals.  Invertebrates  are  consid- 
ered by  the  same  authority  to  have  no  brains,  and  the  ex- 
ample of  the    sanguisuga,  or  common  leech,  the   house  fly, 


216 

etc.,  are  cited.  The  latter  is  an  unfortunate  illustration,  for 
the  fly's  intellig  revealed  in  various  ways,  not  to  the 

same  extent  as  the  ant  and  the  bee,  but  sufficiently  to  indi- 
■  that  it  has  an  organ  ol  limited  intelligence,  like  the 
I,  the  mosquil  Even    the  leech,  though   he  knows 

not  when  to  let  go,  knows  when  and'  where  best  to  hold  on, 
as  I  once  discovered  when  1  got  into  a  colony  ol  them 
while  in  swimming  in  mv  boyhood  days. 

In  man  and  apes  the  cerebellum  is  covered  above  and 
in  front  by  cerebrum.  In  all  the  lower  animals  the  cover- 
ing is  imperfect.  In  man  and  apes  the  cerebrum  is  highly 
convoluted,  the  convolution  becoming  shallower  and  less 
complex  as  we  elcscend  the  scale  of  vertebrate  and  mam- 
mal  life  and   in  imbeciles  and    idiots. 

The  weight  of  man's  brain  is  1  in  prop  irtion  to 

body  weight,  of  all  vertebrate  animals.  Man's  brain  is  said 
to  average  ten  per  cent  greater  in  weight  than  woman's, 
but  the  new  woman  knows  a  good  deal  and  does  not  believe 
it.  The  average  weight  of  the  male  brain  is  about  49  oz. 
Average  weight  of  the  female  brain  44  oz.  Heaviest  normal 
male  brain  65  oz.  Heaviest  normal  female  brain  56  oz. 
Lightest  normal  male  brain  34  oz.  Lightest  normal  female 
brain  31  oz.  Idiots  23  oz.  The  composition  of  the  brain  is 
albumen,  different  phosphates,  salts  and  water.  The  normal 
brain  averages  in  weight  therefore  from  34  to  50  oz.  The 
normal   female  brain  averages  in  weight  from  31  to  44  oz. 

Mental  development  and  power  is  said  to  depend,  all  things 
being  equal,  upon  the  size  and  weight  of  the  brain,  the  com- 
plexity and  depth  of  the  convolutions  of  its  gray  matter.  Fine- 
ness of  texture  has  much,  however,  to  do  with  quality"  of  brain 
and  the  relation  of  brain  weight  and  size  to  size  of  the  frame 
with  capacity.  The  power  of  the  neurone  of  the  gray  cortex 
is  not  yet  exactly  measured.      It  has  been  said  that  Byron's 


217 

hat  was  too  small  for  the  head  of  any  of  his  contemporaries; 
Gambetta's  brain  was  the  smallest  of  any  European  states- 
man, while  an  American  senator  of  ability  (Dunn  of  Indiana) 
is  said  to  have  had  the  smallest  head,  compared  with  the 
heads  of  his  colleagues  (he  wearing  a  6%  hat),  while  the 
biggest  heads  were  owned  by  Benjamin  F.  Butler  and  a 
colored  porter  at  the  Capitol.  Professor  Waldeyer  reported 
to  the  Prussian  Academy  of  Sciences  measurements  of  the 
skull  of  the  Philosopher  Leibnitz,  which  was  discovered  a 
few  years  ago  in  repairing  a  church  in  Hanover.  The  cran- 
ial cavity  measures  1,422  cubic  centimeters,  indicating  a  brain 
weighing  1,257  grammes,  which  is  unusually  small.  The 
contour  of  the  skull  shows  that  Leibnitz  was  of  Slavic  origin. 

Gottfried  Wilhelm  Leibnitz  was  born  in  Leipsic  in  1646. 
He  died  in  1716.  He  studied  law  and  in  1678  was  made  a 
counselor  and  member  of  the  Supreme  Court  by  the  Duke 
of  Brunswick- Luxemberg,  but  his  fame  was  made  by  his 
writings  on  philosophical  subjects. 

Dr.  James  Morris  records  a  brain  weight  of  67  oz. 
belonging  to  a  bricklayer,  who  could  neither  read  nor  write. 
Gambetta's  brain  was  light  weight,  being  about  41  oz., 
while  Byron's  was  heavy,  being  near  64  oz. 

We  know  that  the  intelligence  of  the  ant,  the  bee  and 
the  beaver  are  proverbial,  while  the  eye  of  the  fly  is  quite 
as  perfect  as  that  of  the  ox.  Hydrocephalic  children  and 
some  idiots  have  enormous  heads.  The  heaviest  adult  male 
brain  on  record  weighed  68^  oz.(Nancrede) .  A  brain  weigh- 
ing 66  oz.  belonged  to  the  cranium  of  a  Louisville  baker, 
whose  chief  merit  in  the  world  consisted  in  his  ability  to 
make  a  fairly  good  loaf  of  bread,  and  the  brain  of  an  epi- 
leptic is  recorded  as  weighing  64  oz.,  about  10  oz.  more  than 
Daniel  Webster's.  Cuvier,  the  naturalist,  had  a  brain 
weight   of  64.5  oz. ;  Abercrombie,  the  physician,  of  63  oz.; 


218 

Schiller,  the  poet,  the  same,  while  Agassiz,  an  American 
naturalist,  had  a  brain  weighing  53  oz.  Goodsir,  the  anato- 
mist, had  a  brain  weight  of  57.5  oz.  Dupuytran's  brain 
weighed  but  50.7  oz. ;  Hughes  Bennett,  physician,  47  oz., 
Hausman,  the  minerologist,  43.2  oz. 

Brain  of  an  idiot  (Holden's  Anatomy)   23  oz. 
(Nancrede)   31  oz. 

Epilepsia  and  chronic  insanities  show  high  average 
brain  weights,  while  in  imbecility  the  general  male  average 
is  below,  the  general  female  average  is  above  the  general 
averages  for  the  respective  sexes,  according  to  Crowley 
Clapham's  deductions  from  extensive  research.  In  senility 
and  in  senile  dementia  the  brain  shrinks  in  size  and  loses 
in  weight  in  both  sexes.  Clapham  found  brain  shrinkage 
in  general  paralytics,  but  that  was  in  chronic  insane  asylum 
cases,  after  the  dementia  stage.  There  is  no  evidence  of 
loss  of  brain  weight  in  the  earlier  stages  of  general  paresis. 

The  commissural  fibers  of  the  brain  enter  into  the  com- 
position of  the  corpus  callosum,  the  anterior  middle*  and 
posterior  commissures  bridging  the  third  ventricle.  They 
compose  the  fornix  and  connect  the  two  lateral  hemi- 
spheres; they  enter  into  the  composition  of  the  middle  pe- 
duncles of  the  cerebellum,  which  in  part  serve  to  connect 
the  two  cerebellar  hemispheres;  and  into  the  decussating 
fibers  in  the  medulla  and  pons.  "The  longitudinal  fibers  and 
ganglia  comprise  five  systems:  (1)  The  pedal  system  in- 
cludes the  pyramidal  tract  starting  from  the  parietal  cortex, 
the  anterior  cortical  fibers  from  the  frontal  cortex,  the  lat- 
eral and  posterior  cortical  fibers  from  the  temporal  and  oc- 
cipital cortex,  and  the  caudate  and  part  of  the  lenticular 
nuclei  with  the  fibers    descending  from   them;  these    fibers 

*The  middle  commissure  being  of  gray  matter  and  not  strictly  a  commissure,  though 
it  is  called  the  gray  commissure. 


219 

all  pass  through  the  internal  capsule  and    pedes  crura  cer- 
ebri into  the  pons,  where  all  terminate  except  the  pyram- 
idal tracts,  which  pass  down  to  form  the    anterior   pyramids 
of    the    medulla,  which    are  continuous    with    the    pyramidal 
tract  of  the  cord.       (2)   The  tegmental  system  includes  the 
thalami  optici  with  radiating   fibers  connecting   this    system 
with  the  cortex,  the  longitudinal  fibers  of  the  tegmentum  of 
the    crus    cerebri    of    either  side  with    the    imbedded    nuclei 
(red    nucleus,  substantia    nigra,  corpus    subthalamicum),  the 
tegmentum  of  the  pons,  with  the  locus  ceruleus,  fibers  con- 
necting   the    tegmentum    with  the    cortex,  the    superior  pe- 
duncle   of   the    cerebellum    connecting   the    cerebellum    with 
the    tegmentum,  the    fillet,  connecting    the    nucleus    gracilis 
and  nucleus  cuneatus  of    the   medulla  with  the  tegmentum, 
the  longitudinal  posterior  bundle  of  the  pons,  the  brachia  of 
the  corpora  quadrigemina  and  the  reticular  formation  of  the 
medulla.     (3)     The    system    of   central     (ventricular)     gray 
matter  comprises  the  gray  matter  lining  the    ventricles,  in- 
cluding the  nuclei  of  the  cranial  nerves  adjoining  the  fourth 
ventricles  and  the  tuber  cinereum  on  the  floor  of   the  third 
ventricle.      (4)     The    system    of    outlying    cerebral    ganglia 
comprises   the  corpora    quadrigemina  and    the    external    and 
internal  geniculate  bodies.     (5)   The  cerebellar  system  com- 
prises   the    nuclei    of    the    cerebellum     (corpus    dentatum), 
(emboliform  or  wedge    shaped    nucleus,  roof    nucleus,  etc.), 
with  the    cerebellar  tracts    (inferior    peduncles  of  the    cere- 
bellum   or     restiform     bodies,  connected     below     with     the 
olivary    bodies  and  nucleus  gracilis  and  cuneatus,  and    with 
the  cerebellar  tract  and  posterior  median  and  external   pos- 
terior columns  of  the  cord). 

Look  at  this  brain.  It  is  composed  outside,  of  cin- 
ercious  or  gray  matter,  made  up  of  basal  ganglia,  cortex, 
corpora  quadrigemina,  geniculate  bodies,  ependyma  or  lining 


220 

oi  the  ventricles,  etc.,  nerve  cells  and  connecting  fibers  or 
communicating  neurones;  within  its  white  matter  is  made 
up  of  neurones  forming  longitudinal  and  commissural    fibers 

called  medullated  nerve  fibers.  The  neurones  receive, 
■  up,  au^  manufacture  nervous  energy  and  the  nerve 
fibers  transmit  nervous  energy  and  nervous  impulses  and 
impressions.  The  brain  is  covered  by  these  three  mem- 
branes or  meninges,  first,  internally,  the  pia  mater,  which 
covers  it  closely,  next  the  serous  membrane  or  arachnoid, 
and  the  external  fibrous  membrane  or  dura  mater.  The 
arachnoid  bridges  over  the  large  fissures  of  the  brain  cov- 
ering subarachnoid  fissures  filled  with  cerebro-spinal  fluid. 
The  ventricles  of  the  brain  are  continuous  with  the  central 
canal  of  the  cord  and  the  subarachnoid  spaces.  They  are 
lined  with  a  layer  of  ependymal  glial  cells  and  filled  with 
cerebro-spinal  fluid.  The  brain  is  continuous  with  the 
cord,  its  gray  matter  becoming  internal  and  its  white  mat- 
ter becoming  external. 

It  is  the  function  of'the  brain  in  its  cerebral  cortex  to 
receive  mental  impression,  conduct  intellection  processes 
evolving  and  expressing  emotion  and  thought.  Reception 
of  mental  impression  and  conscious  appreciation  of  sensations 
are  here  located.  They  reach  the  cerebral  cortex  through 
the  nerve  nuclei,  corpora  quadrigemina,  tegmental  system, 
ipital  and  temporo-sphenoidal  cortex,  and  the  peripheral 
communicating  sensory  nervous  system.  The  cortex  of  the 
brain  initiates  voluntary  motions,  including  speech,  and 
receives  conscious  and  unconscious  impressions  from  with- 
out it.  This  takes  place  in  the  fronto-parietal  cortex  or 
psycho-motor  area  and  is  expressed  in  connection  with  the 
motor  nerves  and  pyramidal  tract,  The  brain  produces  and 
regulates  bodily  heat  (caudate  nucleus,  tuber  cinereum).  Its 
medulla  maintains  respiration,  inhibits  the  heart's  action  and 


221 

initiates  and  maintains  deglutition  and  vomiting,  accelerates 
or  inhibits  peristalsis  and  the  various  visceral  operations  are 
increased  or  diminished  by  the  cerebral  cortex,  as  urination, 
defecation,  etc.  Complicated  movements  and  coordinate 
movements  take  place  through  the  cerebellum. 

Consult  your  anatomies  and  physiologies  here  and 
dictionaries  and  medical  encyclopedias  on  the  subject  of 
brain  function  often  in  connection  with  this  course.  Much 
of  this  description  will  be  found  in  Duane's  Dictionary. 

ANTEROPOSTERIOR  SECTION  THROUGH   CEREBRUM. 
FIG.   112. 


Showing  association  neurones  passing  from  fronta  to  occipital  lobe 
and  manner  of  connection  of  pyramidal  cortex  neurones.  A,  C,  B.  a  ter- 
minal axone  at  D,  collaterals  of  association  axones  at  E,  and  cut  ends  of 
crossing  corpus  callosum  fibers  at  f.      (After  Ramon  y  Cajal.) 

This  illustration  was  shown  farther  forward  in  this  course  of  lectures. 

FIG.  113. 

o.£\.<i-c  \ZJW.  cere . 
tit 


SO, 


,.  —  RcppoHs  des  ganglions  cenlraux  isole's  par  leur  face  exlerne 
(hemisphere  gaucne).  —  NC,  noyau  caude ;  —  NL.,  noyau  lenticulaire ;  —  CO, 
couche  optique. 


222 

ADDENDUM. 

The  London  Lancet,  of  November  29,  1902,  referring  ed- 
itorially to  the  weight  of  the  brain  of  man,  analyzes  an  in- 
teresting article  by  Dr.  F.  Marchand,  which  appeared  in  the 
Journal  of  the  Scientific  Society  of  Saxony  (vol.xxvii,  p.  389), 
and  an  abstract  of  the  same,  which  may  be  found  in  the 
Centralblatt  fur  die  Phvsiologie  (1902,  p.  294).  Dr.  March- 
and has  weighed  the  brain  in  1234  cases,  usually  immed- 
iately after  its  removal  frojn  the  body  and  whilst  still  en- 
closed in  the  dura  mater.  The  subjects  were  Hessians,  and 
the  results  which  he  obtained  may  be  briefly  stated  as 
follows: 

The  mean  weight  of  the  brain  in  the  mail  sex  between 
the  ages  of  fifteen  and  eighty  years  was  1400  grammes  or 
43?4  ounces,  apothecary  weight,  and  in  females  it  was  1275 
grammes.  The  brain  in  84  per  cent  of  all  adult  males  be- 
tween the  ages  of  15  and  eighty  years  weighed  between 
1250  and  1550  grammes;  in  about  50  per  cent  it  weighed 
from  1300  to  1450  grammes;  in  about  30  per  cent  it  was 
over  1450  grammes;  and  in  only  20  per  cent  under  1300 
grammes.  In  women  91  per  cent  of  all  the  adults  had  a 
brain  weight  between  1100  and  1450  grammes,  35  per  cent 
weighed  1200  to  1350  grammes,  20  per  cent  over  1350 
grammes,  and  25  per  cent  below  1200  grammes.  Dr. 
Marchand  found  that  the  brain  weight  at  birth  doubled  in 
the  course  of  the  first  nine  months  of  life,  and  trebled  be- 
fore the  expiration  of  the  third  year.  After  this  date  the 
increase  was  much  slower,  and  slower  in  females  than  in 
males.  Its  definite  or  ultimate  weight  was  reached  in  males 
at  about  the  nineteenth  or  twentieth  year,  and  in  females 
from  the  sixteenth  to  the  eighteenth  year. 

The  diminution  of  the  mean  weight  of  the  brain  which 


223 

is  due  to  the  supervention  of  senile  atrophy  occurs  in  males 
in  the  course  of  the  eighth  decade,  and  in  females 
of  the  seventh,  though  without  doubt  great  individual  dif- 
ferences are  observable.  The  increase  of  the  mean  weight 
of  the  brain  in  childhood  follows  the  growth  of  the  body 
generally  till  it  reaches  a  length  of  70  centimeters  inde- 
pendently of  age  and  sex,  but  from  this  point  onward 
it  becomes  irregular  and  is  always  smaller  in  females. 
In  adults  there  is  no  constant  relation  between  body 
weight  and  brain  weight.  Still,  the  mean  weight  of  the 
brain  in  males  of  short  stature  (from  150  to  160  centi- 
meters) is  rather  less  than  those  of  the  average  height,  and 
the  same  holds  good  for  women  under  145  centimeters. 
The  smaller  size  of  the  brain  in  women  is  not  dependent 
on  the  lower  stature,  for  the  mean  weight  of  the  brain  in 
women  is  without  exception  smaller  than  that  of  males  of 
equal  height.  The  conclusions  of  Dr.  Marchand  are  drawn 
from  data  which  are  contained  in  numerous  statistical 
tables. 


224 

In  this  plate  the  student  has  the  opportunity  of  observing  the  gradual 
development  of  the  vertebrata  of  the  encephalon.  The  various  ganglia  of  the 
senses  are  analogous  in  each  species,  varying  but  little  in  size  and  general 
appearance,  the  great  diversity  of  configuration  depending  entirely  on  the 
different  degrees  of  development  of  the  hemispheres  and  cerebellum. 

The  letters  in  this  plate  all  refer  to  the  same  parts  in  each  figure. 

.-/,  Olfactory  ganglion. 

B,  Hemispherical  ganglion. 

C,  Anterior  optic  ganglion. 

/»,  Testes,  or  posterior  optic  ganglion. 

E,  Cerebellum. 

F,  Auditory  ganglion. 

G,  Pneumogastric  ganglion,  or  olivary  body. 
H,  Spinal  cord. 

/.    Tuber  cinereum. 

K,  Posterior  cerebral  ganglion  of  the  cord  or  thalamus  nervi  optici. 

/. ,  Corpus  geniculatum. 

m.  Anterior  cerebral  ganglion  or  corpus  striatum. 

;/.   longitudinal  commissure,  or  fornix. 

0.  Pineal  commissure. 

P,  Intercerebral  commissure. 

1.  Side  view  of  the  brain  of  the  Turtle. 

2.  Side  view  of  the  brain  of  a  bird  (the  Turkey),  with  its  skull. 

3.  The  brain  of  (he  bird  laid  open.     {From  Spurtfieim.) 

4.  Side  view  of  the  head  and  brain  of  a  Squirrel. 

5.  Brain  of  the  Rabbit;    hemispheres  turned    back,  exposing  the  cere- 

bral ganglia  and  optic  tubercles  on  the  right  side;  on  the  left  side 
covered  by  the  fornix  or  longitudinal  commissure. 

6.  Brain  of  the  Squirrel;  hemispheres  separated,  exposing  the  cerebral 

ganglia  of  the  cord. 

7.  Brain  of  the  Rabbit,  under  surface. 

8.  Brain  of  the  Rabbit,  upper  surface. 

For  later  illustrations  and  further  study,  consult  Huxley, 
Ferrier,  Owen,  Wesley  Mills,  Dalton,  His  and  Landois  and 
Sterling,  though  none,  I  think,  have  better  illustrated  the 
subject  for  our  purpose,  while  this  plate  serves  to  keep  the 
name  of  Solly  in  your  mind  as  one  of  the  immortals. 


225 


FIG.   114. 


CHAPTER    XXI. 

THE  BRAIN'S  BLOOD  SUPPLY.* 


THE   INTRA-CRANIAL  CIRCULATION   IN    ITS   RELATION   TO   BRAIN   DISEASE. 

The  heart  in  return  for  its  innervation  from  the  brain 
and  because  of  its  dependence  on  the  brain's  close  prox- 
imity to  it,  sends  the  most  and  the  best  of  its  blood  to  the 
intra-cranial  cavity  to  nourish  first  and  best  of  all  the  cerebro- 
spinal axis,  the  cerebrum,  pons  and  medulla  and  cerebel- 
lum. The  heart  is  the  ceaseless  servant  of  the  brain  and  can 
not  stop  its  action  even  ever  so  briefly  without  the  brain's 
feeling  the  suspended  cardiac  movement  impression  (mo- 
lecular or  en  masse)  in  perversion  of  its  own  function.  The 
heart  ordinarily  reciprocally  responds  in  disordered  action 
or  suspended  function  to  abnormal  states  of  the  brain. 
Functional  cardiac  and  structural  intra-cranial  disease  and 
vice  versa  are  often  mutually  inter-related  and  functional 
states  of  heart  and  brain  are  often  interchangeable  as 
in  the  alternating  or  mutually  related  cardiac  brain  dis- 
turbances of  hysteria  and  epilepsy,  cardiac  vertigo  and 
cerebral  cardiac  arhythmia. 

"Shortly  after  the  blood  leaves  the  heart  a  very  large 
portion  of  it  is  directed  into  four  channels — the  two  carotid 
and    the    two    vertebral    arteries — that    go    direct    and    by 

♦The  quotation  marks  in  this  chapter  refer  to  Dr.  James  Cappie's  succinct  account 
of  the  Intra-cranial  circulation. 

[226] 


227 


branches  to  the  brain,    skull    and    scalp,  the    brain  getting 
mostly  all  of  it. 

"The  course  of  the  carotids  is  upward  on  either  side 
of  the  wind-pipe.  At  the  angle  of  the  jaw  each  divides 
into  two  vessels.  One  of  these  supplies  the  external  parts 
of  the  head,  the  mouth,  pharynx,  etc.  The  other — the  in- 
ternal carotid  — reaches  the  base  of  the  skull,  and  pene- 
trates the  latter  through  a  tortuous  canal.  On  entering 
the  cranial  cavity  it  divides  into  three  branches.  The  an- 
terior and  middle  cerebral  arteries  supply  a  large  part  of 
the  front  and  middle  lobes  of  the  brain,  a  third  proceeds 
backward  and  inoculates  with  another  vessel  from  a  differ- 
ent source. 

"The  vertebral  arteries  take  a  course  less  exposed  than 
that  of  the  carotids.  Each  of  the  cervical  vertebras  has  a 
projection  outward  from  the  side  of  its  body— the  transverse 
process.  In  the  upper  six  vertebras,  each  process  is  per- 
forated by  a  foramen,  and  the  vertebral  artery  is  transmit- 
ted through  this.  It  ascends,  therefore,  through  a  succes- 
sion of  foramina  till  it  reaches  the  upper  part  of  the  spinal 
canal.  There  it  pierces  the  dura  mater,  and  enters  the 
cranial  cavity,  along  with  the  spinal  cord,  through  the 
large  occipital  foramen.  Proceeding  forward,  along  the  base 
of  the  skull,  under  the  medulla  oblongata,  the  two  vessels 
gradually  approach  each  other,  and  at  the  edge  of  the  pons 
varolii  they  unite,  to  form  one  large  vessel — the  basilar 
artery.  From  this  branches  are  thrown  off  to  supply  the 
cerebellum  and  the  posterior  lobe  of  the  brain. 

'The  mass  of  blood  conveyed  by  these  four  arteries  is 
very  large.  It  has  been  calculated  that  they  carry  one- 
fifth  of  all  the  blood  of  the  body.  Even  if  one- half  of  this 
quantity  is  sent  to  the  brain,  the  proportion  would  still  be 
considerable.       The  brain  does  not   weigh  one-fortieth  part 


228 

of  the  whole  body,  yet  it  would    receive    one -tenth    of    all 
the  blood. 

"The  provision  lias  been  made  in  the  brain  to  prevent 
such  a  large  mass  of  blood  from  impinging  too  abruptly 
on  the  delicate  brain  tissue.  In  and  above  its  canal  through 
the  temporal  bone,  the  carotid  is  curved  like  the  letter  S, 
and  the  vertebral  arteries  have  also  a  very  winding  course 
at  the  upper  part  of  the  spinal  column,  and  on  reaching 
the  cranial    cavity. 

"The  arterial  circulation  at  the  base  of  the  brain  is  re- 
markable for  the  manner  in  which  some  of  the  large 
vessels  anastomose.  From  each  of  the  divisions  of  the 
basilar  artery  a  branch  is  thrown  forward,  and  it  inoscu- 
lates with  a  division  of  the  internal  carotid;  and  the  an- 
terior arteries  also  communicate  with  one  another  by  a 
cross  branch.  A  complete  circle  of  somewhat  irregular 
shape — the  Circle  of  Willis — is  thus  formed.  We  can 
readily  understand  how  important  such  an  arrangement  can 
be.  It  makes  provision  for  a  ready  and  full  determination 
of  blood  being  permitted  to  any  part  of  the  brain  where  a 
demand  for  it  may  have  been  set  up."* 

The  Circle  of  Willis  and  the  sigmoid  arrangement  of 
the  internal  carotids  before  entering  the  brain  break  the 
force  to  a  great  extent  of  the  blood  stream  if  too  violently 
impelled  from  the  heart  when  the  heart  is  under  stimula- 
tion. In  the  brain  the  arteries  all  lose  themselves  in  that 
delicate  membrane — the  pia  mater — which  immediately  in- 
vests the  brain.  In  this  membrane  they  divide  and  sub- 
divide into  extremely  fine  terminal  vessels  until  before 
they  penetrate  the  substance  to  nourish  the  neurones  they 
have  become  almost,  if  not  altogether,  brain  capillary  in  size. 
Besides  this  the  cortex  and  basal    arteriole    circulation    does 

*Cappie— Intra-Cranial  Circulation,  Edinburgh,  1890. 


229 

not  anastomose    freely,   nor  do  the  different   cortex  systems 
with  each  other. 

The  intra-cranial  venous  system  of  vessels  also  con- 
trasts remarkably  with  that  of  other  regions. 

"In  the  brain  mass  it  is,  like  the  arterial,  practically 
capillary.  Only  on  reaching  the  pia  mater  do  the  vessels 
so  coalesce  as  to  form  veins  of  appreciable  size.  They 
then,  however,  become  a  conspicuous  object  on  the  cerebral 
surface.  When  the  upper  part  of  the  skull  has  been  re- 
moved, and  the  dura  mater  has  been  cut  away,  the  most 
striking  object  which  presents  itself  is  the  great  number  of 
dark  colored  tortuous  vessels  that  present  themselves  coiled 
in  the  meshes  of  the  pia  mater.  They  are  seen  lying  in 
the  furrows  between  the  convolutions  or  crossing  the  latter 
in  all  directions." 

The  capacity  of  the  veins  throughout  the  body  is,  as  a 
rule,  greater  than  the  arteries  they  accompany  or  cor- 
respond to,  especially  in  the  circulation  within  the  skull. 
While  the  larger  arteries  are  limited  in  number,  the  veins 
of  noticeable  size  are  scattered  over  the  whole  surface  of 
the  brain,  or  lie  in  fine  coils  between  the  convolutions. 

The  pia  mater  or  pia  arachnoid  is  a  unique  complex  of 
vessels  united  by  extremely  fine  fibrous  tissue.  "Through 
one  set  of  these  vessels  all  the  blood  that  goes  to  nourish  the 
brain  must  pass,  and  through  another  set  all  the  returning 
venous  blood  is  transmitted.  The  membrane  keeps  in  close 
contact  with  the  cortical  surface  of  the  brain  in  all  its  foldings. 
While  the  dura  mater  only  dips  between  some  of  the  larger 
masses, — lying,  for  example,  between  the  opposing  surfaces 
of  the  cerebral  hemispheres,  or  separating  the  cerebrum 
from  the  cerebellum, — the  pia  mater  not  only  covers  the 
brain  as  seen  when  the  dura  mater  is  removed,  but  it  dips 
to  the  bottom  of  every  fold,  and    separates  the  layers  from 


230 


one  another.  When  the  convolutions  are  separated,  it  is 
seen  to.  lie  like  a  fine  velvety  pad  between  the  opposing 
surfaces.  At  certain  situations  it  is  continued  into  the 
cavities  or  ventricles.  In  the  lateral  ventricle  in  each 
hemisphere,  the  choroid  plexus — a  curiously  convoluted 
cluster  of  vessels — is  a  conspicuous  object.  If  the  mem- 
brane be  gently  raised  at  any  point,  numberless  extremely 
small  vessels  are  seen  to  connect  its  inner  surface  with 
that  of  the  brain  substance.  These  are  so  delicate  that 
they  break  with  the  slightest  traction. 

"There  is  still  another  peculiarity  in  the  arrangement 
of  the  intra  cranial  blood  vessels.  The  veins,  instead  of 
all  converging  to  form  trunks  differing  only  in  bulk  from 
one  another,  are  emptied  into  what  are  called  the  sinuses 
of  the  dura  mater.  These  are  channels  tunneled  in  vari- 
ous directions  in  that  membrane.  They  are  fifteen  in 
number,  five  being  pairs,  and  five  single. 

"The  most  important  characteristic  of  a  sinus  is  the 
circumstance  that  its  capacity  cannot  be  greatly,  if  at  all, 
altered.  It  is  formed  of  tough,  inelastic  membrane,  and  is 
so  constructed  that  its  walls  can  neither  be  made  to  col- 
lapse by  pressure  from  without,  nor  to  yield  to  distending 
force  within." 

The  falx  cerebri,  which  lies  between  the  cerebral  hemi- 
spheres, is  lodged  in  a  process  of  the  dura  mater.  Beginning 
in  front  at  the  crista  gall i  of  the  ethmoid  bone  in  a  pointed 
fold  of  the  dura,  like  the  point  of  a  scythe,  the  great  longitu- 
dinal sinus  runs  upward  and  backward,  keeping  close  to  the 
cranial  wall  on  its  superior  border,  and  receiving  in  its  course 
the  contents  of  veins  from  the  pia  mater.  If  a  vertical  section 
be  made,  it  is  found  to  be  triangular  in  form,  the  base  being 
outward,  immediately  under  the  cranial  wall,  the  apex  point- 
ing toward  the  center  and  base  of  the  brain.     It  is  small  in 


231 

front  and  increases  gradually  in  size  as  it  runs  backward.  The 
mode  In  which  the  veins  from  the  pia  mater  enter  it  is  also 
peculiar.  They  open  obliquely  in  a  direction  opposite  to  the 
current  of  the  blood  —  that  is  to  say,  while  the  current  in  the 
sinus  is  from  before  backward,  the  veins,  where  they  open 
into  the  sinus,  have  a  direction  from  behind  forward. 

"The  ultimate  destination  of  the  blood  in  the  venous 
sinuses  is  the  jugular  vein,  which  is  reached  by  a  foramen 
different  from  that  by  which  the  arteries  entered. 

"In  the  anatomical  arrangement  and  structure  of  the 
vessels,  the  intra-cranial  circulation  contrasts  in  several 
respects  with  that  of  other  regions  of  the  body.  In  the 
quantity  of  blood  being  larger  in  proportion  to  the  size  of  the 
organ  to  be  nourished, —  in  the  free  manner  in  which  the 
larger  arteries  of  a' system  communicate  with  one  another, — 
in  the  circulation  of  the  brain  mass  being  practically  capillary, 
— in  the  circumstance  that  the  larger  arteries  and  veins,  in- 
stead of  keeping  company,  lie  apart  from  one  another, — 
and  in  the  venous  blood  being  in  the  latter  part  of  its 
course  transmitted  through  channels  with  tough  inelastic 
walls,  we  have  a  series  of  peculiarities  which  has  im- 
portant significance  in  neurological  diagnosis  and  treatment." 
The  great  preponderance  of  blood  in  the  brain  and  the 
brain's  nearness  to  the  heart  and  receiving  its  first  and 
strongest  impulse  from  the  heart,  particularly  in  childhood, 
as  compared  with  other  organs,  accounts  for  the  greater 
proportion  of  circulatory  brain  diseases  in  childhood. 

The  circulation  of  the  brain  being  so  responsive  to  the 
states  of  the  neurones  as  in  the  many  forms  of  induced 
cerebral  hyperaemia  of  over  brain  action  and  gummatous 
adventitia  as  in  epilepsy,  paresis,  insanity,  mania  a  potu, 
etc.,  makes  the  brain  circulation  always  an  interesting 
study  in  neurology.      In  the    phraseology   of   John    Hunter, 


2M 

the  great  English  physiologist  and  surgeon  of  a  former 
century,  the  hlood  seeks  the  remotest  portions  of  the  brain 
under  "the  stimulus  of  necessity."  The  neurones  in- 
ducing the  flow  and  the  nerve  centers  vito- chemically 
appropriating  from  the  blood  current  the  pabulum  of  their 
trophic  reconstruction. 

The  main  current  of  the  circulation  is  carried  on  by 
the  action  of  the  heart.  It  goes  through  the  arterioles 
partly  because  of  the  vis  a  tergo  it  receives  from  the 
heart,  partly  through  the  propulsive  contractions  of  the 
arterioles  and  through  the  induction  dependent  on  the  needs 
and  parts  or  organs.  In  fact  the  local  distribution  of  blood 
is  to  a  great  extent  regulated  by  local  demands  and  con- 
ditions. On  this  subject  Cappie  says:  "As  a  matter  of 
fact  we  find  that  the  supply  of  blood  to  individual  parts  is 
usually  regulated  by  the  need  for  it.  When  the  mammary 
secretion  is  being  established,  the  afflux  of  blood  to  the 
gland  becomes  several  times  greater  than  when  its  function 
was  dormant.  When  the  mucous  membrane  of  the  stomach 
is  stimulated  by  food  and  the  secretion  of  gastric  juice  be- 
gins, the  surface  becomes  intensely  injected  with  rapidly 
moving  blood;  then,  after  digestion  has  been  completed  and 
the  stomach  is  empty,  the  membrane  again  becomes  com- 
paratively bloodless.  In  short,  wherever  growth,  and  espe- 
cially where  the  transformations  that  accompany  functiona 
activity  go  on  with  greater  vigor  than  usual,  there  is  an 
increased  determination  of  blood  towards  and  through  that 
part."  We  have  a  good  illustration  of  this  in  induced  cere- 
bral hyperaemia  following  passionate  mind  excitement,  a  blow 
on  the  head  or  the  rush  of  blood  to  a  part  after  friction  or  a 
moxa  or  blister  sinapism  through  arteriole  dilatation  brought 
about  through  the  paralyzing  influence  of  the  hold  of  the 
vaso- motor  nerve  mechanism  over  the  arterioles,  and  this  is 


233 

brought  about  through  a  vito-chemical  efferent  influence 
going  to  the  vaso-motor  centers,  which  maintains  the  nor- 
mal relations  between  the  tissue  and  viscera  and  the  blood 
supply  in  health  and  cause  those  abnormal  relations  in 
disease  which  we  call  hyperaemia,  anaemia,  etc.  It  is  thus, 
with  this  local  help,  that  the  contraction  of  the  left  ven- 
tricle is  powerful  enough  to  send  the  blood  current  around 
the  body  to  the  right  auricle.  The  circulation  is  completed 
by  the  contractile  vital  and  chemical  assistance  at  the  in- 
termediate arteriole  and  capillary  stations. 

"As  the  vital  affinities,"  quotes  Cappie  from  Alison, 
"obviously  act  with  greater  energy  in  individual  parts  of 
the  body  at  some  times  than  at  other,  (e.  g.,  at  the  lungs 
during  inspiration,  at  the  stomach  during  digestion,  or  at 
the  uterus  during  gestation),  we  can  understand  how  local 
determination  of  blood  should  be  produced  (by  attraction 
rather  than  propulsion)  by  causes  exciting  the  vital  actions 
at  the  ends  of  the  arteries.  The  increase  of  nutrition,  se- 
cretion, or  excretion,  is  in  such  cases,  at  least  in  the  first 
instance,  the  cause,  not  the  effect,  of  the  increased  flow 
of  blood  to  the  parts  concerned ;  just  as  the  excitement  of 
vital  action  in  the  branch  of  a  tree  exclusively  exposed  to 
the  sun,  is  the  cause,  not  the  effect,  of  an  exclusively  in- 
creased flow  of  sap  into  it."* 

"Molecular  tissue  changes  cause  the  movement  of  fluids 
in  capillary  tubes  without  the  aid  of  evident  mechanical 
impulse.  The  movement  in  the  bud  initiates  that  in  the 
stem;  the  molecular  activity  in  the  foliage  conditions  the 
ascent  of  sap  from  a  long  distance  below." 

A  similar  process  for  purposes  of  neurone  nutrition 
goes  on  between  the  nerve  cell  and  its  appendages  which 
make  up  the  nerve  centers  and  the  final  microscopic 
terminals  of  the  arteries. 

♦"Outlines  of  Physiology,"  3rd  ed.,  pp.  62-63,  64-70. 


234 


FIG.   115. 


*B1MMUI 

'd'apres  M.  Charcot).  —  Schema  de  la  circulation  artirielle  dc  la  base 
derencfphale\  —  C,  C,  carotide3  internes;  —  C,A,  cerebrates  antericurcs;  —  S, 
S,  artercs  svlviennes;  —  V,  V,  arteres  vertebrates;  —  B,  tronc  basiliire;  — 
CPartures  ceVebrales  posierieures;  —  1,  2,  3,  3,  4,  4,  arteres  nourriciercs. 

C.L.  Co.fo'txi  Q.rUTc\as_,G/J.Q.^-,Cerlox  G«fce\»x<x\.CXxlct'va.S. 
of  ko-sWevc  cv.xte.1c3.  C.P.  FoWTe-Ttoc  ccxoNdxcA.  (VeXeries., 


235 


FIG.   116. 


Fig.  38. — A,   source  of  vascular  plexus  ;'  B,  triradiate 
•nuclei    in   plexus ;    C,    finer  ramification ;   D    D  D, 
nuclei  and   fibres  of   vascular  and   neural  sheaths ; 
E  E,  large  nerves;  v,  pial  vessel  ;  F,  crossing  vessel. 
(Vvvo-av&erw) 


FIG.    117. 


-Ajgan  jglion  cells  on  vessel  of  pia  materr 


236 


FIG.   118. 


^  .      v.. 


Km.  205:-  Portion  of  tbe  web  of  a  froK's  fool  as  seen  under  a  Jow  magnifying  power,  show  inp 
•.  onecorner  the  pik'Ni.  Huxley;,  "a.  small  arteries 

small  veins.    The  smaller  vessels  are  the  capillaries.    The  course  o(  th? 
bluotl  is  indicated  by  arrows. 


237 


HOW  THE  VENOUS   BLOOD  IS  COLLECTED  FOR  RETURN   FROM  THE 

BRAIN  TO  THE   HEART, 

FIG.    119.  FIG.    120. 


Communication  with  ve/.-is 
^al  back  of  neck 


Interrelation  of  the  transverse 
and  cavernous  sinus  with  the  ex- 
ternal veins  (*).     (After  Leube.) 


Basal  aspect  of  the  sinuses, 
showing  anterior  ophthalmic  and 
Torcular  communications. 


As  the  mason,  building  a  wall  of  brick  or  stone  or 
shaping  its  corners  or  arches,  calls  the  hodcarrier  with  his 
bricks  and  mortar  and  the  hodcarrier  responds  to  his  call, 
so  the  neurone  or  an  aggregation  of  neurones  into  a  nerve- 
center  or  these  aggregated  into  an  organ  when  in  a  state 
of  normal  health,  call  upon  the  blood-carrying  vessels  of 
the  human  organism  for  the  materials  they  need  for  their 
building  and  rebuilding  or  repair.  In  health  they  take  no 
more  and  no  less  than  the  needs  of  their  physiological 
life,  but  in  morbid  states  they  take  less  or  more  and  develop 


238 

local  hyper:emic  or  anaemic  conditions  according  as  they  de- 
mand of  or  receive  from  the  blood  current  too  much  or  too 
little  nutrition  or  suffer  from  too  great  or  deficient  blood 
pressure.  Or  the  neurones  and  nerve-centers  may  act 
abnormally,  if  the  blood  stream  or  the  spinal  fluid  becomes 
toxh;emic  and  carries  blood  poisons  to  the  neurone  beyond 
its  power  to  withstand  and  yet  perform  its  normal  func- 
tion. Morbid  results  then  follow  in  the  neurones,  as  in  the 
psychic  neurones  and  psycho-motor  neurones  toxically  im- 
pressed by  excessive  alcoholic  indulgence. 

Though  the  blood  is  the  life  stream  of  organic  life, 
inherent  conditions  in  the  neurone  determine  and  condition 
the  blood's  distribution  and  appropriation  to  parts  in 
healthy  states.  A  germinal  spot  builds  itself  into  definite 
being  from  its  environing  media,  made  from  the  blood. 
From  this  environment  it  appropriates  the  pabulum  of 
growth  and  converts  it  into  organic  life  and  evolution.  Thus 
it  evolves  into  the  germinal  segment  of  the  brain  and 
spinal  cord  and  completes  a  neuraxis  with  its  vaso- motor, 
psycho-motor,  pure  psychic,  ganglionic,  trophic,  and  motor 
centers,  which  furnish  the  governing  centers  of  the  heart's 
impulses  and  the  arterioles'  contractions  and  dilations  and 
make  a  marvellously  life-endowed  being  of  a  community  of 
centers  of  neural  chain  related  neurones  of  organic  life. 

The  overflow,  or  lack  of  blood,  sent  to  a  part  may  pro- 
ceed from  morbid  states  of  a  distant  vaso-motor  center  as 
in  epileptic  convulsion,  an  overcoming  and  weakening 
physiological  resistance  in  the  neurones  of  other  nerve- 
centers  or  altering  the  functional  display  of  organs,  espec- 
ially of  the  brain. 


239 


FIG.   121. 


TOo 


Normale  Pro-Capfllare  aus  dera 

Oehirn.    Eigene  Beobachtnng. 

Weigert's  Elastica-F&rbtrag. 

a  rothe  Blutkorperchen  im  Lumen. 

6  Endothelkern.    c  Elastica.     d  einiache 

bindegewebslage  der  Adventitia.    e  extra 

adventitieller  Raum.    /  Gliakerne  int 

Hirnparenchym . 


FIG.   122. 


cOtoovC  YjvCWvrv^  (j(X\Kex  Wcn.»,e  o-tvC  Cute) 


240 


FIG.   123. 

V«.T*eY>r«x\  Ck.^iru.Q.^tvic'v^xxv  o.x^4  C\.r\vrvo-t>«.\a-vott\-s. 


.    (atll     ■     .(Kbatirj.  ..  . 
f  byp«rtrcmbl«ehc  P»rti      l 
d<mHtM>B  boi  t     h  arum-btld*t<*  -*"*' 


:,    .!rt    KLfcvlir*   II 


tch*  Fomtd  in  dor  i 


i-i.  d<T  Hum 


nflnnfhmnK   Id 


Pmnrn d«r HucuUrii    I  Klutic*  M'mif  nut  o<-ucfi<iidKon 


FIG.   124. 


tV  d\*~,  SO-  Swb^caX  &p«xoe.  R3-  P^J. 

Sp<xce; . 


FIG.   125. 


241 


Olfactory  bulb  . 


Vertebral  artery 
Anterior  spinal  ; 


Anterior  cerebral ; 


Lamii 

Middle  cerebral  a. 
Tuber  cinereum. 
Mammillary  body- 
Locus  perforatus 

medius. 
Posterior  cerebri.  I  7 

Superior  cerebellar  1 

Pons  Varolii. 

Inferior  cerebellar  s 
Seventh  >  pair  of 
Eighth    {nerves. 

Ninth 
Tenth 


;       \  pair  of 
nthjnerves- 


Twelfth  pair  of 
Cerebellum. 


vA^xlevo-^o^CaVvftx  Ttteo v«xxv  tx-xvri  V&evoX  w,wtar    8w*- 

vessels,  o^  c\t>c\)&  ©^WVYVU,  o-xxS  W<x\A,€Vves  -<£ 
yOc*fzJ  ^jxev/w'voX   icv6xves,    cxwvcv  ce.x>e.\yev    x>ox\.& 

Ce.>ce\QeXVvvTrw.   C  Vxoxvv  cva/3CVvoxs  <Je,xxvoxv,s?CccvV*©xv^ 


242 


FIG.  126. 


Tccmsverse  vtoxvVoA   SetC:votv'1Ocvt:ou^h.  CerfebrcA 


(d"apres  M.  rJiiretl.  — Coupe  transvevsale  des  hemispheres  certbraux 
faitt iu  tin  centimetre  en  nrrit>re'du  chiasma  des  nerfs  optiques.  —  Artires  da 
corps strie;  —  Ch,  chiasma  des  nerfs  optiques;  —  B.  seclion  de  la  bandelctto 
optii|ue;  —  L,  noyau  lcnliculaire  du  corps  strie;  —  I,  capsule  interne,  ou  pied 
de  la  couronnc  rayonnante  de  Red  ;  —  C,  noyau  caude  ou  inlra-ventrirulairc  du 
corps  strie:  —  E,  capsule  cxterne;  — T,  noyau  tcenKorino  ou  avant-mur;  —  R, 
circonvolution  de  ('insula;  —  VV,  coupe  des  ventricules  lateraux;  —  P,P,  pilicrs 
du  trigone:  —  0,  substance  grisc  du  troisiemc  ventricule  qui  so  continue  cij 
arrii'rc  avee  la  couche  optiquc. 

Terriloires  vasculaires;  —  I,  arb"'re  cerebralc  anteriuurc  ;  —  11,  arlerc  tyl- 
vienne  ;  —  III,  artere  cerebrate  posterieure ;  —  1,  artere  carottde  interne ;  -'S, 
arterc  sylvienne; — 3  artere  cerebralc  antericure; —  4,4,  arlercs  exlenies  da 
corps  strie  ou  lenticulft-striecs ;  —  5,5,  artercs  internes  du  corps  strie  (arlerC3 
lenticulaires). 

Cft..  OW\cvSrrv.,5- SecX'vori.  O-pCvc.  xvcxve,  L.  lex>A\cu.\oje   XXU.O- 
Vew.&  o^  ^tS-cxXo.  bodu,    C.  Ccx\.v<5oi,C«,  txux.W\a.s,  £.  E*rfexx\ai\. 

VV  Sccfo-oxv  o^  XoXexcxX  Nje.x\?(x'\.c\e,&,  P.P.  PxYVo.xi  ot  ^CvveFoxxcYx, 
O.  Gfrcx-v^  sv.'bs'Co.xx.ce.  o^Wvro  v«,xAt'vc\e,   vol.^cvxXcocAax'c^Co'cvc.^ 
L  Q.x^'Ce.-c'v.ox  Cecc^broX  cv-xXa-cu, ,X.  Sy^vlcocv  CVa^-CX  ^ ,  IT  "5os1Cex\x}Y 
CctcVcoX  Cv/cCexu, ,  J.  "ixxXc x:\noX  ooocoV-i  Ck-Acx^,  Z.   Sv^-vvolXv  exxXfcxv^ 
3.  C±vXe.x:\t>v   CexabxcCV.   CX-cvex^,  V-.V-.   S^er  *\c>.\  CLrKe.x've.'b  ofj-'CY-vje, 
coxpu.&  ^tx\.oAu.w,  ox>  Vex<t'\.cvC\-o    stxYxxKe  cLxXexves,  »£«5".  iortCev  xvo\ 
evcte*'\.e.s,    or:  \V>_9.    cox^oxo_  s&rvoXo-,    or   VexvX\.c.\A<xx    CX-eVt v-t^>.^. 


The  lenticular  striate  artery  is  the  principal  artery  of  cerebral  hemor- 


rhage. 


243 


FIG.  127. 


^o^<<x\£».nev^  "H\*.  tls.-u,ica.\  Bxftvo\o<y^  o^  GVvrOievVc  &\c«&VaV 


VS«v 


'Swollen    degenerate!  U^, 


Vascular   pjrocess 
ofSpider--eell 


Spinous  extensions  from. 
'        vascular  wails. 


-Degenerating  iferra- 

Us  attacked,    btf 

Spider- calls. 


•cell   with,  its  • 
scui-or^  process. 


Arteriole,   surrounded    hy 
Spicier  elements 


"Degeneration    of    Nerve  -cells    m    Cortex 
with  proliferation    cf  the    Spider    or  Sca-v-en&er-cells.. 
Section  from   fifth    Cortical    layer   m  Motor  xecion. 

210  1    <V*<cf    t^tvcvw,  £jtw\». 


The  above  shows  an  arteriole  of  the  brain  degenerated  by  chronic 
alcoholism  and  the  neighboring  degenerative  changes  of  the  neurones  sup- 
plied by  it. 


CHAPTER    XXII. 

ELECTRICITY   AND   ELECTRICAL   APPLIANCES. 


Electricity  in  medical  practice  is  the  minimization  of  the 
lightning — with  batteries  in  skilled  medical  hands  the  time 
for  fools  in  the  practice  of  medicine  has  passed.  Likewise  for 
fadists  and  fakirs  and  the  reckless, fraudulent  quacks  who  make 
pretense  of  science  and,  for  filthy  lucre,  misapply  this  power 
so  potent  for  the  weal  or  woe  of  man.  The  battery  and  the 
static  machine  are  not  things  to  play  with,  especially  abou't 
the  brain  and  other  nerve  centers.  They  may  destroy  as 
well  as  conserve  structure  and  function.  In  paralysis  there 
must  be  channels  of  nerve  conduction,  anatomically  reestab- 
lished before  the  contractile  power  of  Faradism  should  be 
brought  vigorously  to  bear  on  organic  movement,  otherwise 
you  may  destroy  paralyzed  function  that  is  returning  to 
motor  neurones  by  prematurely  over  violent  electric  con- 
tractile stimulation.  Electricity  is  a  splendid  aid  to  the 
neurologist;  one  of  the  best  aids  he  has  when  properly, 
and  kindly  used  on  the  patient. 

There  are  some  things  we  do  not  quite  understand 
about  electricity  and  until  we  do  we  must  cultivate  its 
acquaintance  with  caution  as  a  therapeutic  agent,  being  sure 
we  are  right  as  we  proceed  with  its  employment  in  treat- 
ment. It  is  friendly  to  our  purposes  in  several  ways,  but 
it  is  also  a  terrible  enemy  and  we  do  not  yet  quite  under- 
stand thoroughly  its  precise  nature.     We  know  it  to    be    a 

[244] 


245 

potent  force  in  nature,  terribly  destructive,  as  we  see  in 
the  work  of  the  unchained  thunderbolt,  when  the  lightning 
strikes  man  or  the  works  of  man.  We  call  it  a  subtle 
fluid.  It  is  latent  in  nature  for  our  use  until  we  arouse  it 
into  activity  by  friction  or  chemical  action.  It  is  the  docile, 
faithful-serving  dog  if  controlled  aright  or  the  destructive  lion 
if  unrestrained.  A  power  that  may  move  mountains,  may, 
if  judiciously  minimized,  curatively  impress  a  neurone,  cere- 
bral, spinal  or  peripheral. 

The  great  big  static  machine,  looking  and  impressing 
the  imagination  like  an  immense  dynamo,  I  do  not  commend 
to  your  use,  but  instead  a  moderate  sized  static  machine 
with  just  potentiality  enough  to  favorably  affect  your 
patients  without  frightening  them  and  a  current  applied 
without  violence.  The  x-ray  machine  may  be  larger  but 
should  be  separate,  and  in  another  room.  The  cautery 
battery  or  the  power  of  the  cautery  battery  of  course,  should 
be  greater  than  for  ordinary  use  and  the  faradic  current 
should  be  as  gently  used  as  will  accomplish  the  necessary 
medical  purpose.  For  the  successful  use  of  electricity  in 
practice  not  quantity  so  much  as  quality  and  skill  are 
needed.  This  applies  to  the  static  breeze  as  well.  An 
excellent  rule  in  the  use  of  electricity  is,  to  paraphrase  the 
surgical  precept  in  regard  to  the  use  of  water  douches  and 
dressings,  to  conform  to  the  feelings  of  the  patient.  Do 
not  persist  in  running  the  static  roller  up  the  hyperaesthe- 
tic  back  of  spinal  irritation,  emitting  or  drawing  sparks  that 
pain  or  shock  and  excite  dread  and  terror.  Use  it  gently  on 
the  naked  skin  with  those  whom  the  current  pains  much. 
There  should  be  more  of  the  placebo  in  your  methods  with 
these  morbidly  sensitive  spines.  Use  the  roller  gently  and 
press  it  closely  on  the  naked  back;  if  otherwise  used  it 
may  greatly  harm  the  patient. 


246 

The  gentle  diffusion  of  electricity  through  the  system 
of  the  patient,  not  in  over  doses,  on  an  insulated  static- 
stand  and  no1  exhaustingly  continued,  supplements  other 
treatment.  It  improves  molecular  activities,  like  a  walk  in 
an  ozonized  and  moderately  sunshiny  atmosphere  or  like 
the  static  breeze.  Some  ozone  is  also  generated  by  the 
friction  battery  and  diffused  in  the  air  in  the  room  about 
it.  The  constant  current  from  forehead  (positive  pole)  to 
nape  of  neck,  (negative  pole),  six  or  more  milliamperes 
with  inch  and  a  half  sponge  electrodes  may  be  used  to 
contract  the  cerebral  arterioles  in  hyperaemic  headache  and 
stronger  in  facial  neuralgia,  sciatica,  etc. 

The  static  and  other  currents  may  be  used  likewise  for 
pain,  but  not  about  the  brain  or  eye  until  you  become  so  expert 
an  electrician  that  you  know  the  subject  and  your  tools  better, 
than  I  can  teach  you  in  this  hour.  If  you  decide  to  use 
electricity  in  your  practice  you  must  make  a  close  study  of 
it  and  qualify  yourself  to  use  it  aright.  Therapeutic  electro- 
cataphoresis  will  interest  you  and  serve  you,  if  you  strive 
to  understand  it  well.  Cataphoresis  carries  medicines  elec- 
trically through  the  system  and  it  helps  to  increase  their 
potency,  in  places,  as  1  think  the  static  insulation  does  in  a 
general  way.  I  have  referred  to  the  use  of  electricity  in 
cephalic  galvanizations  in  a  previous  lecture.  It  is  useful 
for  headaches  and  many  affections  of  the  brain  of  a 
hyperaemic  character,  that  is,  constant  current  galvaniza- 
tions only,  and  the  x-ray  is  now  on  very  promising  trial  for 
cancer.  I  would  try  it  for  brain  tumor  but  you  will  not  be 
expert  enough  in  the  beginning  of  your  practice  to  risk 
this  procedure.  It  has  been  successful.  I  would  advise  its 
use  with  extreme  caution  for  osteo- sarcoma  and  malignant 
growths  under  or  on  the  cranium.  It  has  removed  epithe- 
lioma. 


247 

You  may  use  the  gentle  constant  current  with  safety, 
however.  Incidentally  to  my  neurological  practice  some  results 
with  external  tumors  of  which  I  have  spoken  elsewhere, 
many  years  ago,  were  very  satisfactorily  curative,  which  led 
me  to  the  use  of  the  constant  current  galvanism  in  cases 
of  suspected  brain  tumor  and  gummata  in  epilepsy  and  its 
use  has  been  a  routine  practice  with  me  in  epilepsy  of  all 
kinds  for  a  third  of  a  century  with  very  satisfactory  results. 

.Epilepsy  is  by  no  means  the  inevitably  incurable  dis- 
ease it  has  been  unwisely  proclaimed,  by  men  of  authority 
of  the  past  in  medicine.  1  have  had  many  epileptics  re- 
cover under  persistent  cephalic  galvanization,  coupled  with 
long  continued  treatment  over  several  years. 

Electricity  may  be  used  as  a  tranquilizing  agent  or  as 
an  excitant.  The  former  is  the  best  to  use  generally,  in 
neurological  practice.  It  should  be  so  employed  as  to  soothe 
and  to  calm,  not  only  nervous  conditions,  but  nervous 
apprehensions  and  we  should  be  careful  that  its  psychic 
impression,  by  suggestion,  is  not  counteracted  by  over  vio- 
lent and  too  prolonged  and  exhausting  applications. 
Sometimes,  however,  we  desire  to  produce  a  markedly  ex- 
citant impression,  as  in  chronic  forms  of  paralysis,  when 
precautions  for  ordinary  nervous  excitement  need  not  be 
so  cautiously  considered  and  sometimes  we  may  wish  to 
destroy  tissue,  as  with  the  cautery  or  x-ray,  but  even  then 
we  should  consider  the  patient  and  remember  that  he  has  a 
delicate  sensory  nervous  system  to  deal  with  and  it  is 
closely  connected  with  perceptive  sentient  centers  in  the 
cerebrum.  While  destroying  disease,  we  should  be  careful 
not  to  destroy  vital  cell  life.     Take  care  of  the  neurones. 

Many  styles  of  batteries  and  machines  for  generating 
electricity  are  in  use  which  it  is  not  my  province  to  descant 
upon.       I  show  you  some  samples  which  will  answer   your 


248 

purpose  and  practice.*  Many  electrodes  also  for  applying 
the  fluid  are  employed  and  others  are  being  constantly  devised. 
You  need  one  with  a  current  interrupter  in  the  handle,  if  there 
is  none  on  the  battery,  for  testing  for  the  reaction  of  degen- 
eration until  you  become  adepts  at  opening  and  closing  the 
circuit  otherwise.  1  show  you  some  patterns  devised  by  Erb, 
who  recommends  uniformity  in  size  of  medical  electrodes  for 
conformity  to  a  common  standard  in  medical  case  recording, 
where  electricity  is  used.  1  select  Erb's  also  because  he 
is  something  of  a  pioneer  expert  medical  electrician  after 
Dr.  Benjamin  Franklin  and  John  Wesley.  The  latter  two 
would  be  classed  as  quacks  in  the  business  now  a  days. 
They  were  novices.  There  was  more  Methodism  in  Wesley's 
theology  than  in  his  therapeutics  and  more  science  than 
caution  in  some  of  Franklin's  experiments,  but  he  made 
mankind  greatly  his  debtor  thereby.  He  risked  his  life 
in  the  celebrated  kite  and  cloud  experiments.  Your 
electrode  should  be  supplied  with  a  good  wet  sponge 
or  cover  pad  of  cotton  or  porous  woolen  cloth,  but  neither 
one  need  be  so  large  as  the  one  of  Erb's,  nor  precisely  of 
the  shape. 

If  you  use  electricity,  and  you  ought  to,  you  should 
join  with  a  few  medical  men  and  syndicate  your  business, 
making  a  syndicate  of  three  or  four  and  regulating  the 
demand  on  your  time  so  that  one  of  you  could  study  and 
practice  the  subject  and  accumulate  the  necessary  know- 
ledge and  appliances  for  its  successful  employment,  to  the 
credit  of  the  profession  and  for  the  highest  success  in 
practice.  It  is  a  power  for  good  or  ill  in  medicine  accord- 
ing as  it  is  wisely  or  rashly  employed. 

I  do  not  commend  the  use  of  electricity  to  the  ex- 
clusion of  associated  suitable  medication,  in  practice.      The 

*See  previous  chapters. 


249 

exclusive  medical  electrician  is  usually  lacking  in  necessary 
medical  knowledge  and  consequently  inclined  to  underrate 
or  ignore  medication  and  to  overrate  electricity,  and  to  be 
lacking  in  diagnostic  ability. 

The  best  medical  cataphoresis  in  practice  is  the  in- 
ternal administration  of  a  well  adapted  medication,  based 
on  correct  diagnosis  and  large  neurological  experience,  com- 
bined with  suitable  electrizations. 


CRANIO-CERVICO,   FACIO-CLAVICULAR  POINTS. 
THE  INTER-SCALENI,   SUPRA-CLAVICULAR  POINT  OF  ERB. 

FIG.   128. 


Region-  of  central 
convolutions. 

Region  of  third 
frontal  convolu- 
tion and  island 
of  Reil. 


M.  temporalis 

,1 


U. branch. 

M.branch. 

.  I  Trunk. 

•-L.  branch. 

N.  auricular  post. 

M.  splenius  capitis. 

M  sternocleido- 
mastoid. 

Ti,  accessor  Wil- 
Jisii.    . 
H.-cucullaris. 

N.  dors,  scapulae. 
N.  axillaris. 

N.  thoracic,  long. 
fM.serratus  anti- 
cus. ) 

TJ.  phrenicus. 
"Plexus  brachials. 


M.  orbicular,  pal- 
pebr. 

M.  levator  labii 
super,  alaeque 
nasi. 

Mn.zycomatici. 

M.  orbicular,  oris. 

M.  masseter. 

M.  levator  mentL 

M.  quadrat.  men- 
Li. 
M.trianjrul.menti. 

N.  hypoglossus. 

Platysma 

myc'.rtes. 

Muscles  of  hyoid 
bone. 

N  <horacicus  an- 
terior <M.  pec;' 

ral  major.; 


Supraclavicular  point  of  Erh  (J&rh.  deltoideus. 
supinator  longus  et  brevis,  mfraspi 


bicffps.  brachial,  intern,  [anti^- 
natus  et  subscapularis). 


X  This  is  the  place  of  origin  of  the  birth-arm  palsy  of  Duchenne,  after 
cross-arm  presentation  and  turning  and  of  other  brachial  plexus  paralyses. 


250 


FIG.   129. 


251 


FIG.   130. 


Nrrviis  tibialis. 


~  a         ~  a 


CHAPTER    XXIII. 


THE    DURA;      ITS    SINUSES    AND    DISEASES:      A    CURSORY    ANATOMICAL 
DEMONSTRATION.* 

By  the  assistance  of  Mr.  Norris  we  have  sawed  through 
a  line  around  the  skull,  beginning  about  half  an  inch  above 
the  supra  orbital  ridge  in  front,  going  through  the  two 
tables  of  the  skull  anteriori,  which  inclose  its  frontal 
sinus,  (not  one  of  the  sinuses  we  are  to  consider  today), 
through  the  three  walls  of  the  squammous  and  the  thicker 
and  harder  petrous-temporal  region  and  the  yet  thicker  but 
not  denser  occipital  protuberence  behind.  Prizing  up  with 
a  chisel  the  skull  cap  we  have  just  cut  out,  for 
we  have  not  gone  with  our  saw  entirely  through 
the  inner  table  of  the  skull,  we  expose  this  tough, 
glistening,  fibrous  membrane,  the  dura  mater  or  hard 
mother  membrane  of  the  brain,  showing  also  the 
nutrient  meningeal  arteries  between  it  and  the  skull  cap, 
which  we  have  taken  away. 

This  dense  white  fibrous  membrane  which  our  ancient 
fathers  in  anatomy  thought  when  they  christened  it,  gave 
rise  to  all  the  other  fibrous  membranes  of  the  body,  you 
notice  was  adherent  to  the  inner  surface  of  the  skull  just 
removed,  especially  along  the  median  line  where  the  sagit- 
tal suture  runs   back  to  the    lambdoidal.      As  I  continue    to 

*  Holden's  Anatomy  has  been  mostly  followed  in  this  description,  and  wherever  quo- 
tation marks  appear  in  this  chapter  they  refer  lo  this  excellent  work. 

[252] 


253 

remove  it  you  notice  it  is  adherent  to  the  other  .bones,  es- 
pecially the  petrous,  temporal,  the  cribriform  of  the  ethmoid, 
the  sphenoid,  the  foramen  magnum  or  great  foramen,  and 
that  it  is  studded  with  Pacchionian  bodies  along  this  median 
line,  which  was  here  attached  to  the  skull.  On  its  smooth, 
shining  inner  surface  it  is  lined  by  endothelial  cells. 

The  dura  forms  the  endostium  or  internal  periosteum  of 
the.  skull.     Underneath  it,  is  the  subdural  space.    In  front  it 
projects  downward  through  the  foramen  coecum  and  cribri- 
form plate  of  the  ethmoid  bone,  bringing  the  lining  walls  of 
the  nose  in  intimate  and  remote  connection  with  the  venous 
circulation  of  the  head  in  certain  states  of  venous  congest- 
ion   of    the    brain.     It    connects    with    the    optic   foramen, 
sphenoidal  fissure  and  orbit.    Its  nervous  supply  is  from  the 
fourth  and'  fifth,  including  the  Gasserian  ganglion   filaments 
and    sympathetic    fibers.     Besides  forming  the    cranial    en- 
dostium   it    supports,  encloses    and    protects    the   lobes    and 
otherwise  serves  the  brain.      It  forms  the  falx   cerebri,  this 
sickle    shaped  partition   between  the    hemispheres,  carrying 
the    great  longitudinal    and    lesser    longitudinal    sinuses,  the 
falx  cerebelli  and  the  tentorium  cerebelli.     This  fibrous  tent, 
as  the  name  tentorium  implies,  stretches    across  and  under- 
neath the  anterior  brain  and  over  the  cerebellum.     "It  forms 
the  sinuses  or  venous  canals  for  the  return  of  all  the  blood 
from  the  brain  on  its  way  back  to  the  heart  and  it  sheathes 
the  cranial  nerves  as  they  make  their  exits  from  the  skull. 
It  forms  the  supporting  and  dividing  partitions  between  the 
cerebrum  and  cerebellum  and  the  tentorium  holds   forward, 
in    its  place,  the  cerebrum   and    backward    in  its    place    the 
cerebellum." 

The  tentorium  is  sometimes  found  ossified,  in  lower  ani- 
mals and  by  this  arrangement  confining  the  respective  greater 
and  lesser  brains  more  securely  in  their  respective  places,  may 


254 

account  in  cats  for  the  more  secure  and  superior  safety  over 
that  of  man,  of  the  feline  tribe  in  jumping  head  downward 
from  a  housetop  before  a  boot  jack  or  "any  old  thing" 
hurled  at  Tommy  and  his  musical  friends.  But  human 
acrobats  and  gymnasts  do  similar  feats.  "The  tentorium  is 
attached  to  the  transverse  ridge  of  the  occipital,  the  supe- 
rior border  of  the  temporal  bones  and  to  the  posterior  and 
anterior  clinoid  processes  of  the  spenoid  bone.  In  front,  as 
as  you  see,  the  tentorium  arches  gracefully  over  the  crura 
cerebri,  while  the  point  of  the  falx  cerebri  begins  at  the 
crista  galli  or  coxcomb  like  process  of  the  ethmoid  and 
widens  as  we  trace  it  backward  to  the  manubrium  or 
handle  of  this  sickle  shaped  membrane,  where  it  joins  the 
tentorium  cerebelli.  The  falx  cerebelli  is  also  widest 
and  longest  across  at  its  junction  with  the  tentorium. 

1  do  not  know  for  what  use  these  Pacchionian  bodies 
or  glands  were  formed.  They  are  probably  products  of 
membranous  degeneration.  They  usually  begin  to  appear 
about  the  third  year,  always  by  the  seventh,  and  increase 
as  life  advances,  and  are  said  to  receive  the  fluid  of  the 
subarachnoid  spaces  when  they  have  been  experimentally 
injected.  We  know  too  little  about  them,  considering  that 
they  were  discovered  by  the  Italian,  whose  name  they  bear, 
as  far  back  as  1705.  Perhaps  they  may  have  some  im- 
portant nerve  nourishing,  fluid  overflow  function  or  some 
electro-chemical  relation  to  the  brain  awaiting  your  elucida- 
tion.    Here  is  another  opportunity  for  your  distinction. 

SINUSES  OF  THE   DURA  MATER.* 

The  blood  of  the  cerebral  circulation  is  returned 
through    canals  or    sinuses    formed    by  the  dura    mater,   (as 

*Thls  anatomical  description  is  based  on  and  mainly  abbreviated  from  Holden's 
Anatomy,  the  author's  favorite  dissecting  room  manual  for  this  subject. 


255 

we  have  already  seen  in  a  previous  lecture)  produced  by 
the  dividing  of  the  dura  into  two  layers,  as  shown  in  Fig. 
131,    representing    a    vertical    section      through     the     falx 


FIG.    131. 


J>cxfe*a\ Cross  Section  o^  FoX^CeWbrV 

t-JWf    OF  DofjA 
O  up.  Long. 


Sh 


z.— 


Inf.  Long 


S/flWS 


JhowiivQ  £/vd  view  op  Superior  AND  inferior  lon^ituoinal  qinuses. 

—  CR0&  &£CTt0*,  (SCHEMATIC) 

/.2\t3.  Line  or  fj\l%}  uiPPwgsoWA/  ffemeeN  cerbgral  H£/v\/$pH£Res. 


cerebri,  showing  schematically  a  cross  section  of  the  supe- 
rior and  inferior  longitudinal  sinus.  They  are  lined  by  the 
same  smooth  membrane  continuous  with  that  of  the  venous 
system.  Their  unyielding  walls  resist  the  pressure  of  the 
brain  about  them  and  the  blood  pressure  within  them. 
The  dura  mater  has  fifteen  of  these  sinuses.  Let  me 
recall  them  again:  Five  pairs  and  five  singles.  The 
five  pairs  are:  the  lateral,  superior  petrosal,  inferior  petrosal, 
cavernous  and  the  occipital.  The  five  single  are:  the  su- 
perior   longitudinal,  inferior  longitudinal,  circular,  transverse 


256 

and    the    straight.     They    all    eventually    discharge    their 
venous  blood  into  the  internal  jugular  vein. 

The  superior  longitudinal  sinus,  caused  by  a  triangu- 
lar downward  division  of  the  dura,  as  shown  schematically 
in  the  accompanying  illustration  of  the  falx  cerebri  (Fig.  132), 

FIG.   132. 


The  blood-vessels  of  the  dura  mater.   Lateral  view.    (After  HciUmann.) 


begins  very  small  at  the  foramen  coecum,  it  gradually 
increases  in  size  in  its  course  backward,  and  opposite  the 
internal  protuberance  of  the  occipital  bone,  opening  into  a 
large  vein  somewhat  triangular,  the  torcular  herophili  or  the 
confluence  of  the  sinuses.  "It  then  divides  into  the  right  and 
left  lateral  sinuses,  they  being  generally  the  larger.  Besides 
numerous  veins  from  the  cancellous  texture  of  the  skull 
cap,  the  superior  longitudinal  sinus  receives  large  veins 
from  the  upper  part  of  each  hemisphere  of  the  cerebrum, 
and  an  emissary  vein  through  the  parietal  foramen.  Do 
not  forget  "that  these  veins  run  (as  a  rule)  from  behind 
forward,  contrary  to    the  course    of  blood  in    the  sinus,  and 


257 

that  they  pass  through  the  wall  of  the  sinus  very  obliquely, 
like  the  ureter,  into  the  bladder.  The  probable  object  of 
this  oblique  entrance  is  to  prevent  regurgitation  of  blood 
from  the  sinus  into  the  veins  of  the  brain.  The  superior 
longitudinal  sinus  is  triangular,  with  its  base  upward,  and 
its  cavity  is  intersected  in  many  places  by  slender,  fibrous 
cords,  termed  chorda?  Willisii.t  Their  precise  use  is  not 
understood." 

You  noticed  that  after  stripping  it  from  the  cavity  of 
the  cranium  and  taking  the  brain  out  of  the  cavity,  we  cut 
through  the  dura  mater  with  a  pair  of  scissors,  on  a  level 
with  the  sawn  calvarium.  We  now  strip  the  dura  mater 
from  the  brain  leaving  its  smooth,  convex  surface  exposed. 
"Two  white,  flat  nerves,  the  optic,  come  into  view  prior  to 
their  leaving  the  skull  through  the  optic  foramina;  these 
must  be  divided  and  the  ophthalmic  arteries  which  lie  un- 
derneath the  corresponding  nerve,  cutting  each  pair  of  the 
twin  nerves  first  on  one  side  and  then  on  the  other, 
from  before  backward.  In  the  middle  line  fixed  firmly  in 
the  sella  turcica,  lies  the  pituitary  body,  attached  to  the 
brain  by  the  infundibulum."  This  is  the  important  body 
which  Sajous  has  lately  brought  into  prominence.  "The 
round,  white  nerves,  the  third,  are  on  each  side, 
lying  on  the  inner  free  border  of  the  tentorium  cere- 
belli,  immediately  behind  the  anterior  clinoid  process 
of  the  sphenoid.  Dividing  these,  we  cut  through  the 
tentorium  cerebelli  close  to  its  attachment  to  the  pos- 
terior clinoid  process  and  the  upper  border  of  the 
petrous  portion  of  the  temporal  bone,  as  far  back  as  the 
lateral  sinus.  Immediately  external  to  the  third  nerves  are 
the  slender  fourth  nerves;  and  still  further  outside  are  the 
fifth  nerves.     We  cut  these  through,  when  the  seventh  pair 

tSo  called  after  Willis,  who  first  described  in  his  work,  De*  Gerebri  Anatome,  1664. 


25S 

come  into  view  as  they  pass  backward  and  outward  toward 
the  internal  auditory  foramina.  Cutting  these  we  notice  the 
two  sixth  nerves  running  directly  forward  to  pierce  the  dura 
mater  covering  the  basilar  process  of  the  occiput.  Dividing 
these  three,  other  cranial  nerves  come  into  view,  behind 
and  internal  to  the  seventh;  anteriorly  is  the  glosso- 
pharyngeal immediately,  is  the  pneumogastric  and  poster- 
iorly is  the  spinal  accessory,  whose  origin  is  in  and  below 
the  medulla  and  foramen  magnum.  These  all  emerge 
through  the  jugular  foramina.  Below  and  internal  to  these 
are  the  hypoglossal  nerves,  which  usually  pass  through  the 
dura  mater  into  fasciculi."  The  spinal  cord  has,  you  see, 
been  cut  through  far  down  so  as  to  show  the  relation  of 
the  two  vertebral  arteries,  and  the  spinal  portions  of  the 
spinal  accessory  nerves,  before  this  brain  was  taken  from 
its  bony  incasement. 

The  inferior  longitudinal  sinus,  smaller  in  size,  runs  in 
the  inferior  free  border  of  the  falx  cerebri  and  terminates  in 
the  straight  sinus  at  the    anterior  margin  of   the  tentorium. 

The  straight  sinus  is  the  continuation  of  the  inferior 
longitudinal  running  along  the  line  of  junction  of  the  falx 
cerebri  with  the  tentorium  cerebelli,  and  terminating  in  the 
torcular  herophili  at  the  divergence  of  the  two  lateral 
sinuses.  It  receives  the  inferior  cerebral  and  the  superior 
cerebellar  veins  and  also  the  two  vena?  galeni  (Figs.  132 
and  133)  which  return  the  blood  from  the  lateral  and  the 
third  ventricles  of  the  brain. 

The  cavernous  sinus  is  so  called  because  intersected  by 
numerous  cords  extending  along  the  side  of  the  body  of  the 
sphenoid  bone,  outside  the  internal  carotid  artery,  receiving 
the  ophthalmic  vein  from  the  orbit  through  the  sphenoidal 
fissure  and  the  anterior  inferior  cerebral  veins.  It  commun- 
icates with  the  circular  sinus  which  surrounds  the  pituitary 


259 


FIG.   133. 


Communication  through- parietal 

foramen  with  external  vein*  of  tkutt. 


Ext.  Jugular  oath 

Int.  jugular 
vein 

Interrelations  between  the  superior  longitudinal  sinus  and  the  transverse  sinus  with  the  external 
veins.  (*)     (After  Leube.l 


FIG.  134. 


AnCfaoialveia 


■Ext,  fuguX  «<n 


Communication  with  veisu 
<at  back  of  neck 


Interrelations  of  the  transverse  and  cavernous  sinus  with  the  external  veins.  (*)    (Alter  Leu  be.) 


260 

body.     It    divides    into    the    superior  and    inferior    petrosal 
sinuses. 

The  circular  sinus  or  rather  vein  surrounds  the  pituitary 
body  (see  diagram,  Fig.  134)  and  communicates  on  either 
side  with  the  cavernous   sinus. 

The  petrosal  sinuses  lead  from  the  cavernous  to  the 
lateral  sinuses,  two  on  each  side.  The  superior  runs  along 
the  upper  portion  of  the  pars  petrosa,  in  the  attached  bor- 
der of  the  tentorium  cerebelli;  the  inferior  (larger)  runs 
along  the  suture,  between  the  pars  petrosa  and  the  occipi- 
tal bone,  ending  in  the  lateral  sinus  just  before  this  termi- 
nates in  the  internal  jugular  vein.  The  superior  petrosal 
sinus  receives  the  inferior  cerebral,  the  superior  cerebel- 
lar veins  and  a  branch  from  the  tympanum;  the  inferior 
sinus  is  joined  by  the  inferior  cerebellar  and  auditory  veins. 

The  transverse  or  lateral  sinus  extends  from  one 
inferior  patrosal  to  the  other,  across  the  basilar  process  of 
the  occipital  bone.  It  communicates  below  with  the  an- 
terior spinal  veins. 

The  occipital  sinuses  surround  the  margin  of  the 
foramen  magnum,  run  into  the  falx  cerebelli  and  uniting, 
form  a  single  sinus,  opening  into  the  torcular  herophili. 
They  join  interiorly  with  the  posterior  spinal  veins. 

The  several  sinuses  join  opposite  the  spine  of  the  oc- 
cipital bone  to  form  the  torcular  herophili  or  press  of 
herophilus,  after  the  celebrated  anatomist,  who  first  discov- 
ered it.  "It  is  a  triangular  reservoir,  with  the  base  below, 
and  presents  six  openings,  namely:  that  of  the  superior 
longitudinal  sinus,  those  of  the  two  lateral  and  of  the  two 
occipital,  and  that  of  the  straight  sinus.  The  term  torcular 
is  an  incorrect  version  of  the  original  word  <Tu>\rjv  (a  canal 
or  gutter)  employed  by   Herophilus."     [Holden.] 


261 
LATERAL  SINUSES. 

"There  are  the  two  great  sinuses  through  which  all  the 
blood  from  the  brain  is  returned  to  the  jugular  veins.  The 
right  being  usually  larger  than  the  left  commences  at  the 
internal  occipital  protuberance  and  proceeds  at  first  horizon- 
tally outward,  enclosed  between  the  layers  of  the  tentor- 
ium, along  a  groove  in  the  occipital  bone  and  the  posterior 
inferior  angle  of  the  parietal.  They  then  descend  along 
the  mastoid  portion  of  the  temporal  bone,  indenting  the  oc- 
cipital bone,  turn  forward  to  the  foramen  lacerum  posterius, 
terminating  in  the  bulb  of  the  internal  jugular  veins, 
where  they  are  joined  by  the  inferior  petrosal  sinus,  having 
also  in  some  subjects  other  outlets  through  the  foramen 
mastoideum,  or  the  posterior  condyloid  foramen  of  either 
side.  They  receive  blood  from  the  inferior  cerebral  and 
cerebellar  veins,  from  the  diploe  and  the  superior  petrosal 
sinus,  and  communicate  with  the  veins  of  the  scalp  through 
emissary  veins,  which  pass  through  the  mastoid  and  pos- 
terior condyloid  foramina. 

The  diseases  to  which  the  dura  mater  membrane  and 
its  sinuses  are  liable  are  chiefly  traumatic,  general  and 
specific  inflammations,  thrombosis  and  compression  and 
thrombi  resulting  therefrom.  Inflammations  seldom  involve 
the  dura  alone  but  usually  conjointly  implicate  the  subjacent 
membranes,  the  arachnoid  and  pia  or,  more  properly  called, 
I  think,  the  pia  arachnoid,  as  these  two  membranes  appear 
to  be  an  infold  about  the  brain  like  the  pleura  about  the 
lung.  Remember  the  memorial  word  which  1  have  given 
you  in  our  dead-room  demonstrations,  d.  a.  p.,  (meaning 
from  without  inward)  dura,  arachnoid  and  pia.  Meningitis 
may  be  entire,  or  circumscribed  to  different  meningeal 
areas     as     basilar     and     vertical.        It     may     be     cerebro- 


262 

spinal,  as  in  the  epidemic  form  of  that  disease,  called 
by  the  older  writers  spotted  fever  or  cerebrospinal 
fever.  It  may  be  due  to  syphilis  and  give  the  gam- 
matous  form,  or  to  phthisis  and  appear  as  tubercular 
meningitis,  or  it  may  be  caused  by  the  pneumo-coccus  or 
gonococci,  and  appear  as  pneumonic  or  gonorrheal  forms, 
or  it  may  be  prevalent  or  come  from  various  other  kinds 
of  blood-poisoning. 

Phlebitis  may  involve  the  brain  sinuses  from  causes 
that  produce  inflammation  elsewhere  and  such  inflamma- 
tions may  cause  coagulations  and  adhesions  of  the  venous 
blood  to  the  walls  of  the  sinuses  or  pial  veins,  causing  the 
condition  known  as  thrombosis,  to  which  we  have  referred, 
from  which  small  sections  of  fibrin  may  be  detached  and 
carried  into  the  current  of  the  circulation  as  thrombi,  and 
these  may  lodge  elsewhere  and  act  the  same  as  emboli, 
closing  up  blood  vessels  and  causing  distant  embolism. 

Much  mischief  may  be  done  to  the  delicate  brain  by 
the  pressure  and  destructive  change  wrought  in  the  brain 
even  by  a  single  thrombus  located  in  a  vital  spot. 

Systemic  meningitis  usually  involves  the  pia-arachnoid, 
while  the  traumatic  meningeal  inflammation  generally  in- 
volves  the  dura. 

More  harm  is  done  to  the  brain  by  involvement  of  its 
meninges  than  by  implicating  its  deep  substance,  De- 
pressed fractures  of  the  brain  and  direct  and  counter  stroke 
or  contre  coup  concussions,  often  seriously  involve  the  dura 
and  its  subjacent  membranes  and  their  blood  vessels  and 
give  rise  to  congestive  blood  pressure  states  and  epilepsy 
and  epileptiform  disease.  If  you  remember  the  distinction 
we  made  in  a  previous  lecture  between  neural  and  ad- 
neural  nervous  disease    you    will    recognize  that  meningeal 


263 

and  sinus  diseases,  deranging    the    brain's    functions  often 
begin  as  extra-neural  brain  disease. 

When  the  dura  mater  is  involved  exclusive  of  the  other 
meninges  in  inflammation,  this  condition  is  called  pachy- 
meningitis. When  the  pia  arachnoid  is  involved  to  the 
exclusion  of  the  dura  in  inflammation,  the  condition  is 
called  leptomeningitis. 

The  under  or  inner  surface  of  the  dura  is  usually  the 
seat  of  inflammation  except  when  caused  by  external 
trauma  and  then  cranial  ostitis  may  be  associated  with 
the  endostitis  or  epidural  inflammation.  Extravasations  of 
blood  often  occur  in  connection  with  dura-matritis  and  then 
the  condition  is  called  pachymeningitis  hemorrhagica  interna, 
and  when  these  hemorrhages  become  encapsulated  they 
are  called  hematomata  durce  matris. 

These  hematomata  of  the  dura  mater  often  harmfully 
press  on  the  brain,  compromising  its  functions  and  causing 
coma,  convulsions,  paralysis,  delirium  or  insanity. 

The  meningeal  arteries  supply  the  central  dura  mater 
and  its  innervation  is  derived  chiefly  from  the  trigeminal 
nerves.  The  pia  arachnoid  is  similarly  innervated  and 
from  the  facial  and  spinal  accessory,  glosso-pharyngeal, 
pneumogastric,  the  third  and  the  sympathetic.  This  last 
nerve  accompanies  the  many  vessels  of  the  pia. 

The  dura  mater  is  what  its  name  implies,  the  hard 
membrane,  in  contrast  with  the  other  two  brain  coverings 
which  are  soft  and  easily  torn,  one  of  which,  the  pia 
mater,  being  very  vascular  as  we  have  seen,  and  the  other 
being  without  vessels  and  both  being  delicate. 

Although  the  brain  is  pretty  much  a  plenum,  the  peri- 
vascular spaces  and  ventricles  have  communication  with 
the  spinal  canal  and  thus  the  cerebro-spinal  fluid  admits  of 
some  arterial  hyperemia  and  increased  vascular  distension, 


264 

and  pressure  in  localities  of  the  brain  especially,  if  not  gen- 
erally, throughout  the  brain  and  the  turgid  arteries  and  in- 
creased rapidity  of  their  circulation  may  cause  cerebral 
congestion,  giving  pressure  states  of  the  brain  in  the  arterial 
and  venous  areas  and  causing  hebetude,  coma  and  paralysis. 
Sometimes  the  venous  blood  pressure  is  fortuitously  relieved 
by  epistaxis  through  the  foramen  coecum,  passing  out  through 
the  nares.  You  may  also  have  anaemia  as  well  as  hyper- 
emia cerebri  for  the  same  reasons. 

In  anaemia  the  cerebro-spinal  fluid  of  the  perivascular 
spaces  around  the  arterioles  and  the  ventricles  increases, 
after  maintaining  a  semblance  of  normal  blood  pressure  on 
the  neurones,  without  normal  nutrition,  and  the  brain  may 
functionate  in  consequence  in  a  feeble  but  normal  manner 
in    anaemia.     Besides,  there  may  be  hydremia. 

It  is  not  good  therapeutics  to  arrest  an  epistaxis  while 
the  pulse  is  full  and  strong  and  rapid  (above  seventy-four 
to  seventy-eight).  Sometimes,  in  some  highly  congested 
states  of  the  brain,  it  would  be  wise  to  bring  on  bleeding 
from  the  nose  or  arm.  A  weak  pulse,  bleached  features  and 
faintness  demand  the  immediate  arrest  of  epistaxis.  It  usu- 
ally stops  spontaneously  when  fainting  takes  place.  If  the 
bleeding  is  known  to  be  connected  with  previous  or  present 
anaemia,  and  blood  depraved  states,  as  in  the  adynamia  of 
typhus  or  typhoid  fever  and  other  pernicious  blood  states, 
even  though  there  be  delirium  and  other  head  symptoms, 
bleeding  from  the  nose  is  not  to  be  encouraged. 

If  you  have  a  plethoric,  full-blooded  patient  with  con- 
gestion of  the  brain,  in  whom  nose  bleeding  begins  every 
day  and  finally  stops  of  itself  each  day,  let  this  bleeding 
go  on  daily  unless  your  patient  faints  from  it.  Give  him 
a  daily  chologogue  cathartic  and  bromides,  half  minimum 
doses  of  digitalis,  some  pepsine,  other  digestives  and  a  mod- 
erately low  diet  and  keep  him  free  from  all  brain  ex- 
citement.    Give    him    no    alcohol    stimulants. 


265 


FIG.   135. 


i-Intima  mlt  Enilotfael.-   h  Erasti 


•  Virchow-Robin  —  Lyraphi 


fntravascuJArer 


FIG.   136. 


XXa**wvoJVVe"vtv  o^  Pvew  XXVck?Ce.-<CL 


Nonnale  Vene  aus  der  Pia  mater  des 
Rucken'marks.    Eigene  Beobachtung. 

Weigert's  Elastica-Faibung. 

o  Intima  (Endothelkerne).     b  Elastica. 

c  Media.     &  Adventitia.    e  Blutkbrpercben. 


CHAPTER    XXIV. 


CEREBRAL    EMBOLISM,   THROMBOSIS    AND    HEMORRHAGE,  AND    SOME    OF 
THEIR  SEQUENT   BRAIN  DISEASES  CURSORILY  CONSIDERED. 

Three  of  the  most  important  conditions  of  the  inter- 
cranial  circulation  involving  the  brain  in  grave  disorder  are 
embolism,  thrombosis  and  hemorrhage,  causing  apoplexia, 
aphasia  cerebri,  epilepsia,  etc.,  and  this  is  a  good  place  in 
the  course  to  study  them.  All  three  primarily  involve  the 
circulatory  mechanism  of  the  encephalon  and  secondarily, 
more  or  less,  the  integrity  of  the  brain  texture.  The  two 
former  ordinarily  implicate  the  brain  substance  in  disease 
by  cutting  off  its  blood  supply  and  the  latter  by  flooding 
some  part  of  the  brain  with  blood. 

•  The  former  two  make  their  morbid  mischief  also  by 
pressure  of  distended  blood  vessels,  the  latter  does  its  dam- 
age by  rupture  of  a  blood  vessel  or  vessels  in  the  brain 
and  blood-clot  pressure.  There  is  another  of  congestion, 
in  which  the  circulation  is  involved  in  disturbance  through 
the  nervous  connections  of  its  vasomotor  system  which 
gives  temporary  symptoms  somewhat  like  embolism  and 
hemorrhage  which  we  will  consider  later. 

Embolism,  a  plugging  of  a  vessel,  from  e/*/?oAos,  pointed 
for  plugging,  e/x/foW',  to  thrust  or  put  in,  tixfioX-q  a  putting  into, 
is  the  result  of  the  lodgment  of  a  detached  clot  or  other  float- 
ing body  in  the  current  of  the  circulation  unable  to  go  further, 
by  reason  of  the  narrower  calibei  of  the  blood  vessel  than  at 

[266] 


267 

the  point  of  departure  or  starting  point  of  the  clot,  or  embolus, 
as  it  is  technically  termed.  The  clot  becomes  arrested  in 
its  progress.  It  lodges  and  obstructs  the  circulation.  It  may 
be  a  blood  clot  or  a  number  of  pus  cells  or  fat  cells  or  a  spicula 
or  piece  of  exfoliated  bone  or  a  fibrous  thrombus  from  a  dis- 
tant inflamed  or  stagnant  vessel.  Whatever  it  may  be,  it 
has  migrated  along  the  circulation  to  a  point  distant  from 
its  point  of  origin  and  lodged  there.  Embolism  or  emboly 
is  embolic  invagination,  /'.  e.,  a  plug  or  clot  has  been  thrust 
along  a  vessel  till  the  narrow  caliber  of  the  vessel  will 
permit  it  to  go  no  further. 

After  it  has  lodged  it  begins  to  make  mischief,  to  excite 
inflammation,  to  cut  off  circulation  in  front  of  it  and  dam 
up  circulation  behind  it  and  you  have  a  damned  bad  state  of 
affairs  in  the  brain  where  it  lodges  and  I  do  not  speak  pro- 
fanely either.  The  circulation  is  dammed  where  it  lodges 
and  this  dammed  condition  is  called  embolism  and  the 
physician  coming  to  the  rescue  would  like  to  exclaim  with 
Macbeth,  "out  damned  spot"  and  he  endeavors  to  enforce 
the  command  with  an  all-efficient  therapy  of  reconstruc- 
tion, rest,  diet,  digitalis,  iodides,  bromides,  etc. 

The  onset  of  embolism  symptoms  and  extravasation 
symptoms  are  ordinarily  both  sudden,  those  of  thrombosis 
are  more  gradual.  A  thrombosis  is  caused  usually  by  a 
morbid  slowing  and  vitiation  of  the  blood  as  in  pernicious 
anaemia  or  the  depravity  of  blood  following  typhoid  and 
other  vitiated  blood  states,  as  in  syphilis  and  after  the 
grip,  etc. 

Embolism,  thrombosis  and  hemorrhage  or  extravasation  of 
blood  into  the  brain,  are  apt  to  produce  a  condition  which  is 
called  the  apopleptic  state  or  apoplexy.  But  the  most  common 
cause  of  apoplexy  is  the  rupture  of  a  blood  vessel  into  the 
brain,    and    true    apoplexia    cerebri,  as    distinguished    from 


268 

these  other  conditions  which  may  cause  similar  symptoms 
is  the  result  of  the  breaking  of  a  blood  vessel  into  the 
brain.  It  is  a  stroke  of  cerebral  hemorrhage  and  its  symp- 
toms are  ordinarily  more  sudden  and  graver  than  the  other 
conditions  in  violence  and  sequence,  because  in  apoplexy 
from  cerebral  hemorrhage  or  true  apoplexia,  the  blood  has 
escaped  into  and  torn  its  way  like  a  cataract,  through  the 
delicate  textures  of  the  brain,  separating,  oppressing  and 
destroying  its  psychic  and  motor  neurones  and  pathways  of 
motor  conduction,  causing  coma  and  paralysis,  where  death 
does  not  instantly  follow.  Death  however  seldom  fol- 
lows immediately  on  the  attack,  although  it  may  take  place 
in  a  few  hours  and  this  distinguishes  it,  usually,  from  the 
sudden  death  of  heart  paralysis. 

Apoplexia  from  hemorrhage,  the  true  apoplexia,  results 
from  a  degenerate  state  of  the  vessel  walls,  such  as  follows 
from  syphilis,  gout,  rheumatism,  excessive  alcoholism,  pur- 
pura hemorrhagica,  the  fatty  degenerative  states  that  follow, 
certain  infectious  fevers,  the  degenerative  vascular  states  of 
renal  disease  (uremia,  etc.,),  or  milliary  aneurisms  that 
rupture,  and  the  degenerative  changes  of  age  and  heredity 
that  weaken  the  vessel  walls.  Sudden  congestions,  the  dif- 
fuse periarteritis  of  Charcot  and  Bouchard,  cause  vascular 
degeneration  and  miliary  aneurisms  that  rupture.  They 
are  a  most  frequent  cause  of  apoplexy,  which  is  also  excited 
and  precipitated  by  violent  emotions,  mental  shock  or  sud- 
den physical  exertion. 

Apoplexia  derives  its  name  from  the  fact  of  its  being  a  sud- 
den stroke  or  seizure,  from  the  Greek  {airo-rrXyj^  airoTrXyjcnTuv, 
to  strike  down) .  It  is  always  sudden  in  its  onset  but  not  always 
complete  in  its  symptoms,  from  the  beginning.  It  is  usually 
characterized  by  sudden  seizure  and  coma.  The  very  nature 
of  its  cause,  the  pouring    out    of    blood    into    the    delicate 


269 

meshes  of  the  brain,  accounts  for  the  sudden  coming  on  of 
coma.  It  thus  resembles  epilepsy  in  its  onset,  for  it  some- 
times also,  when  the  middle  cerebral  artery  in  its  cortical 
motor  area  is  ruptured,  shows  convulsions  as  one  of  its 
symptoms.  When  it  does  this  it  is  very  like  epilepsy  for 
awhile.  But  if  you  wait  awhile  the  epileptic  will  recover, 
say  in  half  an  hour  or  a  little  more  or  less  time.  The  apo- 
pleptic  will  not.     His  symptoms  will  deepen. 

There  is  also  another  exceptional  form  of  apoplexy 
which  somewhat  resembles,  but  faintly,  for  a  little  while 
an  epileptoid  seizure.  It  is  called  ingravescent  apoplexia. 
The  patient  has  vertigo  but  not  entire  loss  of  consciousness, 
resembling  a  vertiginous  epileptic  seizure.  He  has  no  con- 
vulsions. Wait  a  little  while  here  and  you  can  make  your 
diagnosis  easily.  For  the  patient  may  complain  of  head- 
ache and  vomit.  He  will  have  hemiplegia  and  hemianes- 
thesia after  the  time  for  your  epileptic  to  recover. 

Before  the  day  is  over  and  after  your  epileptic  shall 
have  recovered  and  gone  about  his  way,  the  coma  of  in- 
gravescent apoplexia,  first  beginning  in  stupidity,  will  have 
set  in  and  neither  nitrite  of  amyl  nor  time  will  arouse  your 
patient  from  it,  for  he  is  going  to  die  of  a  rupture  of  a 
branch  of  the  lenticular  artery  into  the  corpus  striatum  prob- 
ably near  the  external  capsule  and  this  blood  is  going  to 
find  its  way  into  the  lateral  ventricle,  may  be,  and  kill  your 
patient  in  the  course  of  a  few  days,  not  more  than  five  or 
six.  Be  careful  of  your  prognosis  in  apoplexia,  even  though 
your  patient  be  conscious  in  the  beginning  and  the  grave 
symptoms  only  come  on  gradually. 

Examine  Edinger's  beautiful  illustrations  of  lesions  of 
apoplexia  and  the  investigation  will  make  you  cautious  as 
to  prognostication  when  blood  gets  in  among  the  neurones 
and  commissural  and  projection  fibres    of  .  the    brain.       Yet 


270 

apopleptics  recover  and  recover  quite  often  after  the  first 
attack  if  they  are  judiciously  handled  'and  have  not  been 
injudiciously  dosed  with  alcoholic  stimulants  in  the  begin- 
ning, so  long  as  they  can  swallow.  Ingravescent  apoplexia 
begins  out  toward  the  external  capsule  of  the  corpus  stri- 
atum and  works  inward.  Symptoms  of  lesion  of  the  in- 
ternal capsule  vary  according  to  the  location  of  the  lesion 
in  the  anterior  or  posterior  portion.  The  capsule  is  never 
implicated  alone  to  the  exclusion  of  the  nuclei  in  extrav- 
asation. 

If  it  were  possible  to  restrict  the  infusion  of  blood  to 
the  anterior  limb  of  the  internal  capsule  we  would  have  no 
marked  symptoms.  When  you  have  the  ordinary  hemi- 
plegia of  an  ordinary  apoplexia  the  blood  extravasated  is 
pressing  on  the  upper  and  anterior  two-thirds  of  the 
posterior  limb  or  the  posterior  portion  of  the  anterior  two- 
thirds  or  both.  The  leg  is  most  involved,  the  hemorrhage 
is  chiefly  in  the  posterior  portion  of  the  anterior  two-thirds. 
But  both  thigh  and  leg  and  arms  on  the  opposite  side  are 
usually  involved. 

The  hemorrhage  of  apoplexia  may  be  in  the  cortex  or 
any  part  of  the  brain  but  it  is  usually  in  the  corpus  stri- 
atum and  lateral  ventricles,  in  the  sylvan  fissure  or  in  the 
pons  and  fourth  ventricle.  There  is  also  sometimes  a 
pseudo  or  spurious  apoplexia  causing  hemiplegia,  coma  and 
death  from  pure  congestion  of  the  brain.  .  The  older  writers 
reported  such  cases,  demonstrating  post-mortem  diffuse 
hyperemia. 

Hemorrhage  into  the  pons  is  a  grave  affair,  usually  in- 
volving the  eye  and  throat  muscles,  sometimes  causing  con- 
vulsions. The  temperature  runs  high,  the  respiration  becomes 
slow  and  otherwise  disturbed,  the  patient  swallows  badly,  has 
crossed  paralysis  and  bilateral  and  unilateral  limb  paralysis 


271 

and  sometimes  bilateral  paralysis.  The  fourth  ventricle  is 
liable  to  become  gravely  implicated  and  death  to  follow. 

The  fourth  ventricle  is  also  often'  involved  in  cerebellar 
apoplexy  and  the  patient  has  coma,  and  the  respiration  may 
suffer  as  in  pontal  hemorrhage.  The  hemiplegia  of  apoplexia 
is  ordinarily  not  on  the  same  side  as  the  lesion,  but  may 
be  here.  In  pontal  hemorrhage  certain  nerves  will  aid  in  the 
diagnosis.  In  its  gray  substance  are  the  nuclei  of  the  sixth, 
seventh  and  motor  branches  of  the  fifth  cranial  nerves  and 
fronting  the  pons  near  the  median  line,  on  the  inner  border 
of  the  crus  cerebri,  is  the  third  nerve,  while  on  the  outer 
margin  of  the  crus,  where  the  pons  overlaps  it,  emerges 
the  fourth  nerve,  near  where  the  fifth  nerve  comes  out  of 
the    pons. 

Hemorrhage  into  the  medulla  causes  symptoms  similar 
to  those  of  bulbar  paralysis  and  often  death  in  a  short 
time.  The  fourth  ventricle  is  likely  to  be  involved,  causing 
slowed  respirations  and  slowness  of  the  circulation  shows 
medulla  hemorrhage  involvement  also. 

Cerebral  hemorrhage  as  you  see  may  occur  in  any 
part  of  the  brain  and  so  may  embolism  and  thrombosis  and 
those  aneurisms  or  abnormal  distensions  with  destructions  of 
the  inner  coats  or  intima  of  the  arteries  which  form  those 
favorite  seats  of  rupture  to  which  I  have  referred.  Wherever 
there  are  blood  vessels  to  break  or  small  enough  to  stop  a 
floating  plug  or  diseased  enough  to  arrest  the  circulation 
and  cause  the  blood  to  coagulate  and  its  fibrine  to  adhere 
to  the  vessel  walls,  there  you  may  have  these  different 
destructive  diseases  of  the  brain  in  the  order  named,  name- 
ly:  hemorrhage  or  apoplexy,  embolism  or  a  plugged  up 
brain  artery  and  its  consequences  and  that  other  condition 
like  unto  embolism,  which  we  call  thrombosis;  like  em- 
bolism in  its  effects  on  the  brain,  but  unlike  it  in  the  way 


272 

it  comes  on.  Thrombosis  comes  on  slowly  because  it  is  a 
disease  connected  with  a  vessel  wall  or  a  slow  blood  cur- 
rent that  comes  on  slowly  and  makes  its  mischief  at  its  home, 
/'.  (•.,  at  the  place  of   its  formation  and  development.      The 

thrombus,  which  is  the  adherent  clot  on  the  vessel  wall,  is 
apt  to  gradually  widen  out  and  more  and  more  obstruct  the 
circulation.  It  may  be  likened  to  a  Mississippi  River  sand- 
bar or  to  a  dead  tree  that  has  fallen  from  the  bank  which 
at  first  makes  a  small  obstruction  to  the  channel  but,  by 
gradual  accretions,  the  obstruction  enlarges  until  the  natural 
channel  of  the  river  is  no  longer  navigable,  when  the  gov- 
ernment employs  the  surgery  of  the  dredge  boat  to  re- 
move the  obstruction  and  clear  the  channel  for  a  freer 
circulation  in  this  great  artery  of  our  inland  mid-state  com- 
merce. The  thrombus  is  a  stationary  snag  that  has  grown 
out  at  the  spot  where  it  has  first  formed  and  has  done  or  is 
doing  all  its  harm  in  its  own  home.  It  may  be  a  sedimentary 
deposit  from  the  blood,  or  the  fire  of  an  inflammation  of  vein 
or  artery  may  b*  lodging  its  debris  there.  This  condition  of 
affairs,  the  thing  itself,  with  the  neighboring  morbid  condi- 
tions created  by  it,  is  called  thrombosis  and  thrombosis  of 
the  brain  often  causes  a  crisis  in  a  man  or  woman's  life. 

The  embolus  acts  differently.  Though  comparatively 
harmless  at  the  spot  where  it  has  developed,  a  little  clot  of 
fibrine  from  the  margin  of  a  heart  valve  or  slight  phlebitis 
of  the  leg  for  instance,  when  it  goes  away  from  its  home  and 
lodges  and  it  there  suddenly  makes  trouble,  often  far  away 
from  its  place  of  origin.  It  gets  into  the  smaller  arteries  of  the 
delicate  regions  of  the  brain  and  disregarding  the  physio- 
logical porprieties,  plugs  one  of  them  up;  the  speech  center 
branch  of  the  middle  cerebral,  for  example,  (  the  inferior 
frontal  branch  of  Broca's  convolution),  and  the  neighborhood 
is  speechless;   aphasia  results;   or  it  gets  into  another  branch 


273 

of  this  same  important  middle  cerebral  artery,  going  to  the 
lenticular  nucleus  and  plugs  up  the  artery  that  Charcot 
called  the  artery  of  cerebral  hemorrhage  because  it  was  so 
commonly  the  seat  of  rupture  and  it  there  causes  a  condi- 
tion like  that  of  true  cerebral  apoplexy,  viz.:  a  sudden 
stroke  of  coma  with  paralysis  of  the  opposite  side.  Although 
all  three  of  these  conditions  of  the  brain  may  exceptionally 
take  place  wherever  there  are  blood  vessels  to  rupture  or 
plug  or  to  become  thrombotically  obstructed.  The  most  com- 
mon seat  of  apopleptic  hemorrhage  is  in  the  V  art  ere  de  V  hem- 
orrhages cerebral,  as  M.  Charcot,  the  distinguished  immortal 
savant  of  Paris,  has  named  and  placed  it.  The  favorite  seat 
of  cerebral  embolism  is  also  in  some  branch  of  the  middle 
cerebral  and  usually  in  the  first  or  inferior  frontal  branch  to 
Broca's  convolution  and  the  locality  of  thrombosis  is  preferably 
in  the  cerebral  sinuses  and  veins  of  the  lower  extremities. 
Cerebral  embolism  is  more  common  in  the  Sylvian 
artery  of  the  left  side  than  elsewhere  in  the  brain,  causing 
that  interesting  condition  called  aphasia  by  which  the  ca- 
pacity to  formulate  and  comprehend  speech  or  word  character 
ideas,  is  thereby  impaired  or  destroyed.  This  site  of  lodg- 
ment for  the  embolic  clot  floating  in  the  current  of  the 
circulation  is  selected  by  the  emboh  s  because  the  vis  a  tergo 
of  the  blood,  the  force  of  the  circulation  from  behind,  because 
the  force  of  the  heart  impulses  drives  it  there  more  readily. 
The  carotid  artery  on  the  left  side  leaves  the  aorta  in  a 
straighter  line  upwards  on  this  side  than  on  the  right  side. 
The  carotid  on  the  right  side,  as  you  see  by  reference  to 
the  plate  on  the  wall,  comes  off  from  the  artena  innom- 
inata  at  a  right  angle  or  nearly  so.  It  is  therefore  easier 
for  an  embolus  to  be  driven  into  the  left  than  into  the 
right  carotid,  and  having  got  there  it  goes  on  till  it  encoun- 
ters a  diameter  in  the  vessel  walls  too  narrow  to  permit  it 


274 

to  pass.  It  usually  goes  to  the  first  branch  of  the  Sylvian, 
the  one  that  leads  to  Broca's  convolution  or  the  Broca  area 
of  the  third  frontal  convolution  and  either  lodges  at  the 
bifurcation  or  stops  a  little  way  within  one  or  the  other  of 
its  branches.  When  the  clot  lodges,  it  clogs  up  the  artery 
as  suddenly  as  a  rupture  opens  in  hemorrhage  and  the  first 
symptoms  may  be  very  like  those  of  sanguineous  rupture 
apoplexy,  viz.:  sudden  coma  and  hemiplegia,  but  as  the  coma 
passes  away  and  the  hemiplegia  mitigates  some,  perhaps,  you 
find  aphasia  revealed.  The  patient  can  move  his  voice  muscles, 
lips  and  tongue,  but  cannot  speak.  But  this  entire  middle 
cerebral  or  Sylvian  fissure  artery  is  an  exceedingly  important 
artery  for  you  to  consider.  Besides  sending  on  the  left 
side  branches  that  sustain  the  integrity  of  the  speech  cen- 
ter in  health,  and  similar  branches  to  the  corresponding  but 
ordinarily  latent  or  inactive  branches  on  the  opposite  side, 
it  supplies  the  central  cortical  psychomotor  areas  of  both 
sides  of  the  brain,  the  cortical  auditory  centers  with  their 
nutrition  and  has  even  something  to  do  in  the  way  of 
nourishing  the  visual  areas  of  the  brain.  The  middle  cer- 
ebral artery  is  in  fact  the  most  widely  distributed  of  the 
three  main  or  upper  cerebral  end  arteries. 

Of  the  two  other  cerebrals,  as  we  have  said  in  a  pre- 
vious lecture,  which  it  will  do  you  no  harm  if  we  repeat, 
the  anterior  cerebrals  supply  chiefly  the  corpus  callosum  and 
the  anterior  and  mesial  aspects  of  its  abutting  convolutions 
the  first  and  second  frontal,  and  paracentral  lobule  and 
precuneus.  The  posteriors  supply  the  occipital  and  temporal 
lobes,  the  cuneus  and  the  cms  cerebri  of  either  side  and 
send  a  branch  to  the  optic  thalmus. 

There  is  an  absence  of  free  anastomosis  between  the 
branches  of  the  cerebral  system  arteries  which  go  to  the 
cortex  and    those  which  go   to  the  basal  ganglia,   but  when 


275 

the  carotid  is  ligated  on  one  side  a  sufficient  anastomosis 
tardily  takes  place,  if  the  patient  recovers  from  the  opera- 
tion, as  he  often  does,  to  re-establish  the  general  circula- 
tion of  the  brain. 

This  shows  that  anastomosis  may  become  more  com- 
plete under  stress  than  some  observers  have  asserted  in 
the  discussion  of  what  they  have  termed  the  end  arteries 
of  the  brain's  circulation.  The  basal  ganglia  and  the  cortex 
arteries  do  not  anastomose. 

Hemorrhage  into  a  ventricle  usually  means  speedy 
death.  Into  the  fourth  ventricle  and  iter  and  from  it  to  the 
third  it  is  always  fatal.  Hemorrhage  into  the  pontal  and 
medulla  area  leads  usually  to  a  tardier  but  no  less  certain 
death,  I  have  seen  death  occasionally  averted  where  the 
fourth  ventricle  was  not  involved.  In  the  corpus  striatum 
it  is  more  hopeful  and  if  the  bleeding  be  in  the  cortex,  in 
the  Rolandic  fissure  area,  you  may  have  convulsions,  but  the 
outcome  is  the  most  hopeful  of  all,  especially  after  a  first 
attack.  The  same  is  true  of  embolism  there.  Cerebral 
thrombosis  is  always  of  grave  import.  An  ultimate  danger 
from  rupture,  embolism,  and  thrombosis  is  cerebral  softening. 

A  cursory  glance  again  at  the  remaining  brain  circula- 
tion may  aid  your  reflections  on  the  subjects  of  embolism, 
thrombosis  and  hemorrhage. 

The  posterior  inferior  cerebellar  arteries  sometimes 
coming  from  the  basilar,  but  more  often  from  the  vertebral 
and  going  to  the  under  surface  of  the  cerebellum,  divide 
there  into  two  branches,  one  branch  going  to  the  fourth 
ventricle,  the  other  between  the  cerebellar  hemispheres. 
Of  the  branches  of  the  basilar,  one  goes  to  the  internal  ear 
on  each  side,  one  goes  to  the  anterior  inferior  portion  of 
the  cerebellum,  supplying  its  front  and  lower  surfaces  and 
blending  with    other  cerebellar  arteries.     Superior  cerebellar 


276 

arteries  come  off  also  from  the  basilar  and  go  to  the  upper 
surface  of  the  cerebellum  and  anastomose  with  the  inferior 
cerebellar,  going  also  to  the  pineal  body,  the  valve  of 
Vieussens  and  the  velum  interpositum.  The  posterior 
cerebral  arteries  are  two  terminal  branches  of  the  basilar, 
following  the  cranial  nerve,  winding  round  the  crura  cerebri 
and  distributing  themselves  to  the  posterior  cerebral  lobes, 
dividing  there  into  many  branches  and  anastomosing  with 
the  anterior  and  middle  cerebral.  They  receive  communi- 
cating arteries  from  the  internal  carotids,  supplying  the 
posterior  perforated  space  and  the  small  posterior  choroid 
artery  which  goes  to  the  velum  interpositum  and  choroid 
plexus. 

These  conditions  of  the  plugged  vessels  and  basilar  or 
obstructed  vessels,  causing  symptoms  so  much  like  those 
resulting  from  extravasation  of  blood  into  the  brain, 
may  be  called  the  embolic  or  thrombotic,  hemorrhagic  or 
apoplectic  equivalents,  just  as  the  premonitory  symptoms, 
the  forewarning  transient  vertigos  with  motor  weakness  and 
heaviness  and  altered  sensations  in  hand  or  foot  or  tongue 
are  called  symptomatic  epileptic  equivalents,  sometimes. 

Disturbances  of  this  kind  should  attract  your  attention 
and  receive  your  treatment.  They  indicate  varying  states 
of  blood  pressure  in  the  brain  and  should  be  corrected 
promptly,  especially  if  your  patient  has  reached  the  age  of 
possible  arteriole  degeneracy  or  if  by  reason  of  syphilis  or 
alcoholism  or  other  cause  you  have  reason  to  suspect  ar- 
terial wall  disease.  Syphilis  and  alcoholism  are  the  most 
common  causes  of  apoplexy,  and  rheumatism  is  the  most 
common  cause  of  embolism.     But  there  are  other  causes. 

Hemorrhage  or  embolism  involving  the  hinder  or  lower 
part  of  the  posterior  limb  of  the  internal  capsule,  besides 
the  more    or    less  one  sided   paralysis,  would  produce  hem- 


277 

ianassthesia  and  special  sense  anaesthesia  or  paralysis,  be- 
cause the  sensory  fibers  pass  here  to  the  opposite  side  of  the 
body  and  special  sense  fibers  passing  through  here  would  give 
hemianopsia,  and  eye  movement  disturbances  would  show 
that  the  trouble  extended  up  to  the  genu  of  the  cap- 
sule. Through  it  pass  fibers  from  the  cortex  to  the  nuclei 
of  the  motor  oculi  •  nerves.  You  would  have  also  facial  and 
taste  distortions,  if  the  facial  and  hypoglossal  nerves  were 
impinged  upon.  The  internal  capsule,  remember,  is  a  con- 
densed compact  bundle  or  band  of  motor  and  sensory  pro- 
jection fibers  on  their  way  to  important  business  below  the 
brain  in  the  cord  and  if  they  are  intercepted  by  a  flood  of 
blood  or  a  plugged  up  and  compressing  artery,  they  can 
not  do  their  work.  Their  messages,  motor  or  sensory,  from 
above  or  below  can  not  be  delivered.  We  shall  probably 
refer  to  this  subject  again  in  the  clinics  and  again  perhaps 
in  discussing  the  subject  of  epilepsy,  which  in  its  beginning 
is  like  apoplexy,  for  comparison,  especially  in  its  prodromal 
aura. 

Hemorrhage  is  more  common  in  men  than  in  women, 
because  man  dissipates  more  and  lives  more  recklessly  and 
less  guardedly  and  is  more  exposed  to  the  brain  artery 
damaging  influences  of  alcoholic  and  venereal  diseases  of 
the  blood  vessels  and  because  his  life  is  more  strenuous 
and  more  irregular.  From  these  and  other  causes  blood  vessel 
disease  of  the  brain  falls  more  upon  man  than  upon  woman. 

Embolism,  on  the  contrary,  is  quite  as  common  in 
woman.  Its  chief  remote  cause  is  rheumatism,  and  women 
are  equally  as  prone  to  this  as  men.  The  rheumatic  fever, 
and  fibrinous  exudates  about  the  heart  valves  furnish  most  of 
the  emboli  which,  dislodging  and  entering  the  current  of 
the  circulation,  float  on  till  they  lodge  again  in  a  narrow 
artery  of  the  brain  and  form  the    condition  of  cerebral  em- 


278 

holism,  which  is  a  sudden  suspension  of  the  Drain's  func- 
tion by  the  migration  but  sudden  lodging  of  a  clot  within  the 
walls  of  one  of  the  cerebral  arteries.  While  true  apoplexia 
or  brain  hemorrhage,  by  contrast,  is  a  blood  clot  escaped  as 
blood  but  coagulated  outside  of  the  artery  among  the  neurones 
and  neuroglia  of  the  brain.  In  embolism  it  is  the  gloved 
hand,  in  hemorrhagic  apoplexia  it  is  the  bare  hand  that 
gives  the  foudroyant  stroke,  as  the  French  call  it.  But  in 
both  it  is  a  knock  out  and  often  fatal  blow,  for  coma  is 
common  and  unimpaired  consciousness  is  rare,  in  either 
embolism  of  the  brain  or  hemorrhage.  It  is  seldom  that 
either  come  on  gradually.  The  phlebites  of  pregnancy  may 
cause  fatal  thrombi. 

Cerebral  thrombosis  though  more  commonly  the  result 
of  other  causes,  some  of  which  I  have  mentioned,  espec- 
ially in  women,  is  in  men  often  the  result  of  the  same 
arterial  condition  that  most  frequently  causes  cerebral  hem- 
orrhages, especially  in  men  past  middle  age,  viz.,  atheroma. 
That  peculiar  degenerative  process  diminishes  the  caliber 
of  the  cerebral  blood  vessels,  intercepts  circulation  and 
causes  coagulation  from  the  blood  current,  especially  in  old 
people  who  show  an  aptitude  toward  blood  coagulation  by 
arterial  wall  inflammation  or  profound  ana?mia.  Abnormally 
sluggish  circulation  or  inherent  tendency  of  the  fibrine  of 
the  blood  to  separate  and  deposit  itself  from  any  cause,  and 
adhere  to  the  vessel  walls  and  cut  off  blood  supply  by 
occlusion  and  softening  of  the  area  these  vessels  ought  to 
nourish,  results  in  damage  to  the  brain  if  the  vessel  dis- 
ease is  there. 

Women  sometimes  have  thrombi  and  thrombosis  from 
depravity  of  the  blood  in  the  puerperal  state  and  men  and 
women  have  this  condition  of  the  circulation  after  basilar 
meningitis  and  both  also    may  have    it   from  traumatism  of 


279 

the  head.  It  is  always  interesting,  however,  and  often  it  is 
especially  so  to  the  surgeon  in  other  parts  of  the  body  than 
the  brain.  Because  it  cuts  off  the  life  of  the  tissues  sup- 
plied and  necrosis  of  the  part  results. 

The  brain  may  soften  when  its  arterioles  cease  by  throm- 
bosis, embolism,  atheroma,  extravasated  clots  or  traumatic 
severance,  to  nourish  it.  A  condition  technically  called  cer- 
ebral necrosis,  or  cerebral  malacia,  or  encephalo  malacia, 
takes  place  and  there  is  no  place  in  such  territory  of  the  brain 
for  a  normally  working  neurone.  There  are  none  to  work 
normally.  They  are  stunned  out  of  existence  or  otherwise 
destroyed.  The  damaged  vessels,  veins,  venules,  arterioles 
and  arteries  shrink,  the  perivascular  and  other  lymph 
spaces  enlarge.  The  neurones  and  their  neuraxones  and 
dendrites  become  macerated  and  lifeless,  the  neuroglia 
swell  and  yellow  softening  sets  in.  Later  this  area  of 
softening  is  absorbed  and  may  become  encysted  much  like  a 
blood  clot  after  a  hemorrhage,  if  the  patient  does  not  die 
from  the  exsanguined  pressure  upon  the  brain.  Still  later  the 
walls  which  have  surrounded  and  enclosed  this  clot  of  blood 
and  this  debris  of  neuro-vascular  destruction  arresting  its 
further  invasion  and  making  it  harmless,  may  become  yet 
further  conquered  by  indominably  conservative  nature.  Its 
walls  may  be  brought  together  into  a  narrow  cicatrized 
sclerotic  scar,  to  mark  like  a  monument  of  victory  over  an 
invading  enemy,  all  that  remains  of  his  once  destructive 
march.  Especially  is  this  so  in  the  brain's  cortex  surface, 
if  more  area  of  destruction  shows  in  indurated  pia  mater 
and  serous  exudation  beneath,  atrophy  and  induration  still 
yellowishly  discolored  may  be  seen,  like  the  yellow  flag 
which  floats  over  the  military  hospital  mingled  with  white, 
sometimes,  on  the  field  of  a  recent  battle. 

You  will  remember  this  contest    between  the  resisting, 


280 

rebuilding  and  reorganizing  forces  of  nature  in  the  human 
organism  and  its  enemies,  won't  you?  It  is  always  on 
guard  in  the  battle  of  the  organism  for  its  life.  Our  fore- 
fathers lauded  it  as  the  vis  medicatrix  natures. 

Softening  from  either  thrombosis,  embolism  or  extrav- 
asation in  the  brain  might  take  place  less  frequently  had 
Nature  been  less  conservative  in  her  distribution  of  the 
blood  vessels  of  the  brain.  That  is  had  she  made  a  com- 
plete anastomosis  throughout  the  whole  of  the  cerebral  blood 
vessels  instead  of  having  modified  communication  between 
those  of  the  cortex  and  the  basal  ganglia.  But  perhaps 
had  she  done  this  there  might  have  been  too  much  vascu- 
lar response  to  the  play  of  the  emotions  and  man  might 
have  had  too  much  induced  cerebral  hyperemia  responsive 
to  intellectual  or  cortex  excitation.  What  would  have  be- 
come of  the  delicate  basal  ganglia  if  they  were  subject 
to  every  varying  blood  flow  of  the  emotional  or  passionate 
intellectual  life  of  the  gray  matter  of  the  brain? 

Holden  in  his  excellent  anatomical  description  of  the 
brain's  circulation  reminds  us  of  the  important  fact,  besides 
the  tortuosities  of  the  arteries  and  the  break  in  the  force 
of  the  arterial  blood  flow,  by  reason  of  the  Willisian  cir- 
cle arrangement  and  the  arteries'  passage  through  tortuous, 
bony  canals,  to  get  to  the  brain,  of  the  spreading  of  the 
arterial  ramifications  in  that  very  delicate  membrane,  the 
pia  mater,  as  if  to  try  the  effect  of  their  force  there,  before 
Nature  would  permit  them  to  enter  the  delicate  substance 
of  the  brain.  He  calls  attention  to  the  minuteness  of  the 
capillaries  and  the  extreme  thinness  of  their  walls,  the 
formation  of  the  venous  sinuses  which  do  not  accompany 
the  arteries,  the  chorda?  Willisii  in  the  superior  longitudinal 
sinus,  the  absence  of  valves  in  the  sinuses  and  the  con- 
fluence of  the  six  sinuses  forming   the  torcular  herophili  at 


281 

the  internal  occipital  protuberance.  These  facts  of  the 
cerebral  circulation  are  important  for  us  to  remember  in 
estimating  the  delicate  brain's  capacity  of  tolerance  of  its 
rushing  blood;  the  ability  of  its  delicately  constructed 
neurones  and  their  connecting  neuroglia  under  the  brain's 
normal  arterial  blood  pressure,  to  do  the  fine  work  of  trans- 
muting impressions  into  emotion,  motor  impulses  and 
thought.  It  is  this  remarkable  arterial  network  arrange  - 
ment  which  the  great  Galen,  as  Holden  also  reminds 
us,  called  the  rete  mirabili,  enabling  the  brain  to  work 
composedly  in  its  normal  state  amid  the  rush  of  blood 
from  the  carotids  and  vertebrals  and  to  make  that 
blood  subserve  the  purposes  of  its  own  reconstruction 
and  of  receiving  impressions,  forming  and  reforming 
reflections,  without  being  overwhelmed  by  the  brain's 
flood  of  blood  from  the  heart.  This  is  why  the  delicate 
neurones  of  the  psychic  brain  centers  can  resist  so  much 
of  the  punishment  unwise  man  would  inflict  upon  it  by 
excessive  brain  stimulation  and  overstraining,  circulation 
exciting  indulgences.  But  the  brain,  notwithstanding,  can- 
not endure  everything  man  puts  upon  it  and  will  not  endure 
the  blood  pressure  whirl  of  daily  cerebral  hyperemia  which 
the  reckless  custodians  of  really  good  encephalons  impose 
upon  it  without  protest  in  pain  or  altered  function,  and 
surrender  to  the  destruction  of  disease.  The  brain  has  a 
way  of  its  own,  crying  out  against  the  violence  of  the 
reckless  and  vicious. 


2S2 


FIG.    13; 


(\\\\«,to.«v<Aovx'b  I?  e, o>e.vve.xdkvoxx  o^ \V\fc  peciCVcoc  (XvKaxx^. 


Atheromatbse  Degeneration  der  Art.  basilaris. 

a  gewueherte.  kemreiche  Intima.    *  in  fettighyaliner  Umwandlang  begriflene  gewnchene  Intima 

c  Fragmentation  der  veranderten  Elastica  int     d  Atrophie  der  in  hyaliner  Degeneration  befindlichen 

JIu-.1ul.1r15     t  Adventitia.    /'  Spaltraum   zwuchen   der  Elastica  interna  und  der  tayalin  degenerirtsm 

Intimasklenose-     Eigene  Beobacbtung 

(Nacli  No/we  und  Luce.) 
SECTION  OF  BRAIN,  SHOWING  GUMMATA. 
Original    observations  by  M.  Nonne  and  H.  Luce. — Flautau,  Jacobson 
and  Minor's  Handbook  of  the  Pathological  Anatomy  of  the  Nervous  Systems. 

FIG.   138. 


Partie  aus  einem  Cummi  an  der  Hinibasis      HamatoxylinF.ubung. 
In  samratlichen  Gefiissen  ist  das  Lumen  stark  vercngl.  bei  o  obliterirt  .  ill  den.  Lumni  .1-1  auderen 

QeflSM  tindet  sicb  noch  ctwasBlut  (M  (rothe  Bliukm-perchem      Di<-  \  erengeruiig  des  l.i. ns  k.niimt 

»uf  Rerbnang  der  Proliferation  der  Intima  (el     Media  und   Adventitia  Sim    von  gleielim.isMg   .-„i- 

jitndlicb  innltnm-m  Gcwebe  -  das  an  dlener  St.- ,00b  nielli  nekrotiscb  1st  -  verdecki 

Eigene  Beobacblung 


CHAPTER    XXV. 

THE  ANATOMY    OF  THE  SPINAL  CORD,   WITH    BRIEF   REFERENCE   TO 
ITS   MORBID  STATES. 


In  your  dissections  of  the  spinal  cord  when  the  arches 
of  the  vertebrae  are  sawed  through  and  removed,  the 
spinal  cord  comes  into  view.  The  cord  does  not  occupy  the 
entire  cavity  of  the  spinal  canal.  The  dura  mater  does  not 
adhere  to  the  vertebrae  clear  down  the  canal  and  does  not 
form  their  internal  periosteum  or  endosteum  as  in  the 
skull.  Between  the  walls  of  the  spinal  canal  formed  by 
the  spinal  bones,  and  this  membrane,  a  space  intervenes, 
which  is  filled  with  soft,  reddish  looking  fat,  with  watery 
cellular  tissue  and  the  ramifications  of  a  plexus  of  veins. 

"The  spine  is  remarkable  for  the  great  number  of 
large  and  tortuous  veins  which  ramify  about  it  inside  and 
outside  the  vertebral  canal.  These  veins  are  the  dorsi- 
spinal  or  posterior  external  veins  which  form  a  tortuous 
plexus  outside  the  spinous,  transverse  and  articular  pro- 
cesses, and  the  arches  of  the  vertebrae,  communicating 
with  corresponding  veins  above  and  below,  ending  in  the 
plexus  inside  the  vertebral  canal.  They  join  the  vertebral 
veins  in  the  cervical  region,  the  intercostal  in  the  dorsal, 
and  the  lumbar  and  sacral  veins  below." 

"The  veins  of  the  bodies  of  the  vertebrae  {venae  basis 
vertebrarum)  emerge    from    the    backs    of    the    bodies     and 

[283] 


284 

empty  themselves  into  the  transverse  veins,  connecting  the 
two  anterior  longitudinal  spinal  veins.*' 

The  tortuous  anterior  longitudinal  spinal  veins  run  the 
whole  length  ol  the  spinal  canal  and  receive  opposite  each 
vertebra,  the  venae  basis  vertebrarum. 

"The  posterior  longitudinal  spinal  veins  run  also  along 
the  whole  length  of  the  spinal   canal." 

The  anterior  and  posterior  longitudinal  spinal  veins 
are  situated  between  the  spinal  canal  and  the  dura  mater 
of  the  spinal  cord,  and  are  called  the  meningo-rachidian 
wins,  and  the  medulli-spinal  or  proper  veins  of  the  spinal 
cord  within  the  dura,  form  the  fine  plexiform  arrange- 
ment of  veins  over  the  surfaces  of  the  cord.  They  ap- 
pear so  distinct  that  they  can  with  difficulty  be  injected 
from  other  spinal  veins.  These  veins  discharge  themselves 
through  the  intervertebral  foramina  in  the  several  regions 
of  the  spine,  the  cervical  emptying  into  the  vertebral  veins, 
the  dorsal  into  the  intercostal  veins,  the  lumbar  into  the 
lumbar  veins.  They  are  not  provided  with  valves,  and 
often  become  congested,  in  spinal  disease.  They  may  be 
the  seat  of  embolism  in  sluggish  states  of  the  spinal  cord 
circulation  and  in  spinal  phlebitis. 

The  membranes  of  the  spinal  cord  are  the  same  in 
number  and  continuous  with  those  of  the  brain,  but  they 
differ  from  the  brain  membranes  in  their  attachments. 

Tlie  dura  mater  of  the  cord  is  tough  and  fibrous,  like 
that  of  the  brain  in  structure,  but  it  does  not  adhere  to  the 
bones,  being  separated  from  them  by  fat,  loose  areolar  tis- 
sue, and  the  plexus  of  veins  referred  to.  This  loose  arrange- 
ment or  absence  of  attachment  of  the  dura  mater  to  the 
inner  spinal  canal  wall  permits  the  free  movement  of 
the  vertebrae.  Adhesion  would  impede  this,  neither  is 
the  cerebral    dura    mater   everywhere    adherent  to  the    inner 


285 

walls  of  the  cranium,  being  most  markedly  adherent  along 
either  side  of  the  falx  cerebri  and  great  longitudinal  sinus, 
where  the  Pacchionian  bodies  are  mostly  found  in  our  dis- 
sections. The  spinal  dura  mater  is  attached  firmly  above 
to  the  margin  of  the  foramen  magnum,  and  by  slender  tis- 
sue to  the  posterior  common  ligament,  and  may  be  traced 
downward  as  a  sheath,  as  far  as  the  second  bone  of  the 
sacrum,  from  which  it  is  prolonged  as  a  fibrous  cord  to  the 
coccyx,  where  it  becomes  continuous  with  the  periosteum. 
It   forms  a  complete    canal  or  bag   or  sheath   {theca)   which 

FIG.  139. 


DIAGRAM   OF   A   TRANSVERSE   SECTION  THROUGH    THE   SPINAL   CORD   AND    II 
MEMBRANES. 


i.  Dura  mater. 

2.  Arachnoid  membrane. 

3.  Ganglion  on  posterior  root  of 

spinal  nerve. 


CHel^tx) 


4.  Anterior  root  of  spinal  nerve, 
5,. 5.  Seat  of  sub-arachnoid  fluid. 
\oPosterior  branch  of  spinal  nerve 
7.  Anterior  branch  of  spinal  nerve. 


surrounds  loosely  the  spinal  cord,  and  is  relatively  larger  in 
the  cervical  and  lumbar  regions  than  in  the  dorsal.  On 
each  side  are  two  openings  in  the  dura  mater  for  the  an- 
terior and  posterior  roots  of  the  spinal  nerves,  and  the  mem- 
brane is  prolenged  over  the  trunk  of  each  of  the  spinal 
nerves.  These  prolongations  accompany  the  nerve  only  so 
far  as  the  intervertebral  foramina,  and  are  there  blended 
with  the  periosteum.  The  inner  surface  of  the  dura  mater 
is  lined  with  a  smooth  layer  of  polygonous  or  many-sided 
secreting  cells,  yet  sometimes  called  the  parietal  layer  of 
the  arachnoid  membrane. 


If  you  cut  through  the  nerves  which  proceed  from  the 
spinal  cord  on  each  side,  an  J  remove  the  cord  with  the 
dura  mater  entire,  then  slit  up  the  dura  mater  along  the 
middle  ol  the  front  of  the  cord  and  examine  the  arachnoid 
membrane  you  will,  from  its  anatomical  structure,  note  that 
the  functions  of  the  dura  mater  of  the  cord  are  not  identical 
with  the  encephalic  dura  mater  since  it  does  not  here  form 
internal  periosteum  to  the  bones  of  the  spinal  canal;  nor  does 
it  send  in  partitions  to  support  the  cord;  and  it  does  not  split 
to  form  venous  sinuses,  as  the  dura  does  in  the  brain. 

The  arachnoid  membrane  of  the  cord  is  a  continuation 
from  that  of  the  brain,  and  is  reflected  over  the  spinal 
nerves  as  they  pass  from  the  cord  to  the  apertures  in  the 
dura  mater.  This  membrane  invests  the  cord,  and  is  in 
contact  by  its  superficial  aspect  with  the  dura  mater,  there 
being  an  interval  between  them  called  the  subdural  space, 
although,  in  some  cases,  they  are  more  or  less  connected  by 
connective  tissue  bands.  On  its  deeper  surfaces  it  is  in 
contact  with  the  pia  mater,  but  is  loosely  connected  with  it 
by  delicate  areolar  tissue,  so  there  is  a  considerable  in- 
terval between  them  (sub-arachnoid  space),  which  is  occu- 
pied by  a  transparent,  watery  fluid  (cerebro- spinal  fluid) 
contained  in  the  meshes  of  the  sub-arachnoid  tissues.  The 
separation  between  the  arachnoid  and  the  pia  mater  varies 
in  the  different  parts,  and  is  greatest  in  the  lowest  part  of  the 
cord. 

The  cerebro-spinal  fluid  will  claim  attention  from  you 
in  practice.  It  amounts  to  one  or  two  ounces  or  slightly 
more  or  less  and  makes  the  watery  cushion  of  the  cord  to 
protect  it  in  a  measure  against  spinal  irritating  motion  and 
slight  concussions  of  brain  or  cord.  It  consists  of  ninety- 
eight  and  five-tenths  per  cent  water  and  one  and  five- 
tenths  solid  matter.      It  distends  the   theca  or  sheath  of  the 


287 

cord  and  softly  cushions  the  cord  against  violence,  in  run- 
ning, jumping,  falls,  etc.  An  old  physiological  anatomist, 
Haller  by  name,  discovered  it  and  another  distinguished 
physiologist,  Magendie,  demonstrated  it.  He  sawed  away 
the  arches  of  the  vertebras  of  animals  and,  puncturing  the 
dura  mater  of  the  cord,  saw  jets  of  fluid  issue  from  beneath 
the  punctured  sheath.  He  called  this  cerebro-spinal  fluid, 
the  cephalo-rachidian  liquid.  If  we  could  get  out  all  the 
serum  of  the  perivascular  and  subarachnoid  spaces  we 
should  find  more  than  two  ounces  of  this  fluid. 

The  spinal  fluid  is  called  cerebro-spinal  fluid  because  it 
communicates  through  the  fourth  ventricle,  as  stated,  with 
the  general  cerebral  and  ventricular  serum  cavities  and 
with  the  serum  of  the  spinal  cord. 

The  cerebro-spinal  fluid  comes  into  notice,  especially  in 
early  infancy,  when  the  fontanelles  distend  or  flatten,  ac- 
cording to  the  extent  of  the  pressure  of  this  fluid  and  in  spina 
bifida  where  the  spinous  processes  do  not  unite  at  the 
proper  time  of  evolution  for  them  to  come  together.  If  you 
press  over  the  fontanelles  of  such  a  child  the  tumor  in  the 
spine  will  enlarge,  and  if  you  press  back  the  distended 
fluid  from  the  spine,  the  fontanelles  will  swell  out.  If  you 
confine  the  fluid  in  the  head  by  steady  uniform  pressure 
and  press  on  the  spina  bifida  tumor  at  the  same  time,  you 
elicit  symptoms  of  neuraxis  (or  cerebro-spinal  axis)  pressure, 
such  as  vertigo,  or  suspended  consciousness,  suspended 
ability  to  feel  or  move.  This  experiment  of  nature  con- 
firms the  results  of  laboratory  experimentation.  The  cer- 
ebro-spinal fluid  should  be  allowed  to  escape  but  sparingly 
in  the  therapeutic  procedure  of  spinal  puncture  for  cocain- 
ization  of  the  cord.  Spine  puncture  and  cerebro-spinal 
drainage  is  coming  into  use  in  these  days  of  the  mar- 
velous   medical  advance    now  on  and    before    you,  for  relief 


288 

in  certain  conditions  of  excessive  brain  or  cord  pressure, 
like  hydrocephalus,  serous  apoplexy,  etc.,  and  for  purposes 
of  cerebo-spinal  medication  besides  anaesthesia  and  for 
diagnostic  purposes.  We  are  probably  on  the  threshold  of 
a  new  cerebro-spinal  therapy,  a  neuraxis  cerebro-therapy. 

The  cerebro-spinal  fluid  has  indirect  relation  to  the 
serum,  occupying  the  perivascular  spaces  about  the  blood 
vessels  of  the  brain  and  thus  becomes  related  to  states  of 
pressure  about  the  blood  vessels,  as  we  have  seen,  and  to 
anaemia  and  to  the  healthy  tone  of  the  brain.  This  sub- 
ject will  occupy  our  further  attention  at  another  time. 

To  find  the  cerebro-spinal  fluid  on  dissection  the  cord 
must  be  examined  soon  after  death  and  before  the  brain 
is  removed.  The  nerves  proceeding  from  the  cord  are 
loosely  surrounded  by  the  sheath  of  the  arachnoid.  But 
this  only  accompanies  them  as  far  as  the  dura  mater,  where 
the  two  are  continuous.  The  cerebro-spinal  fluid  of  the 
cord  communicating  with  that  of  the  brain,  and  also  with 
the  general  ventricular  cavities  and  perivascular  spaces  has 
important  neurological  bearing,  as  we  have  seen  in  dis- 
cussing the  brain's  circulation. 

The  pia  mater  of  the  cord  immediately  invests  the  cord 
and  its  protection  differs  in  structure  from  that  of  the  brain. 
It  is  not  a  membrane  filled  with  minute  arteries,  but  it  sup- 
ports and  strengthens  the  cord,  as  the  dura  does  the  brain. 
It  is  less  vascular  and  more  fibrous  in  structure  and  more 
adherent  to  the  substance  of  the  cord.  It  sends  down  thin 
folds  into  the  anterior  and  posterior  median  fissures  of  the 
cord,  and  is  prolonged  upon  the  spinal  nerves,  forming  their 
investing  membrane  or  neurilemma. 

Along  the  anterior  median  fissure  runs  a  well-marked 
fibrous  band  formed  by  the  pia  mater,  the  linea  splendens. 

Below  the  level  of  the  second  lumbar  vertebra,  the    pia 


289 

mater  is  continued  as  a  slender  filament  called  the  filum 
terminale,  or  central  ligament,  which  runs  down  in  the  mid- 
dle of  the  bundle  of  nerves  (the  cauda  equina)  into  which  the 
spinal  cord  breaks  up.  About  the  middle  of  the  third  sacral 
vertebra  it  becomes  continuous  with  the  dura  mater  of  the 
cord,  and  is  then  prolonged  as  far  as  the  base  of  the  coccyx. 
The  spine  of  the  third  sacral  vertebra  marks  the  level  to 
which  the  cerebro-spinal  fluid  descends  in  the  vertebral 
canal.  It  is  supplied  with  nerves  from  the  sympathetic  and 
from  the  posterior  roots  of  the  spinal  nerves. 

FIG.   140. 


A 


< 


M 


I.  Dura  mater. 
2,2,2.  Ligamenturn  denticulaum 


QioUtr?) 


The  ligamenturn  denticulatum  connects  at  each  side  of  the 
cord  along  its  whole  length  with  triangular  or  dentate 
fibrous  bands.  This  series  of  processes  steadies  and  sup- 
ports the  cord  in  its  place  in  the  spinal  canal.  The  bases  of 
these  dentate  bands  are  attached  to  the  cord,  and 
their  points  to  the  inside  of  the  dura  mater.  There  are 
from  eighteen  to  twenty-two  of  them  on  each  side  of  the 
cord  and  they  lie  between  the  anterior  and  posterior  roots 
of  the  spinal  nerves.  The  first  process  passes  between  the 
vertebral    artery    and    the    hypoglossal    nerve;    the  last    is 


290 

found  at  the  termination  of  the  cord.  It  is  composed  of  fi- 
brous tissue  and  is  covered  with  nucleated  cells  continu- 
ous with  the  arachnoid  membrane. 

The  membranes  of  the  cord  will  interest  you  in  con- 
nection with  spinal  meningitis  or  cerebro-spinal  menin- 
gitis, which  is  an  inflammatory  condition,  also  tubercular 
meningitis,  diphtheria,  and  the  tumors  of  the  cord.  About 
all  the  tumors  of  the  cord,  except  glioses  and  gliomata, 
originate  in  the  membranes.  Gliomata  and  glioses  are 
developed  from  the  glia  tissue,  called  also  neuroglia.  Glio- 
mata are  malignant. 

Neuromata  and  sarcomata  form  in  the  spinal  nerve 
roots,  brain  or  cord  substance  and  cranial  nerves.  Gliomata, 
tubercles  and  sarcomata  often  originate  in  the  gray  matter 
or  the  cord.  Echinococci  are  generally  found  external  to 
the  dura.  Cysticerci  are  found  in  the  brain  and  cord  sub- 
stance sometimes. 

Lipomata  are  indolent,  slow-growing,  fatty,  painless  tu- 
mors often  found  in  the  skin  on  scalp.  Their  super- 
ficial existence  might  warrant  us  to  suspect  them  to  be  also 
deep  seated,  in  certain  states  of  the  nervous  system.  Pay 
close  attention  to  the  chair  of  surgery,  when  tumors  are 
discussed  there.  Most  tumors  of  the  coverings  of  cord  are 
small,  of  slow  growth,  growing  by  preference  up  or 
down  the  cord  and  beginning  after  an  injury  to  the  cord  or 
spinal  trauma,  as  spinal  cord  wounds  are  surgically  called. 
Syphilomata  and  certain  cancers  grow  rapidly.  Spinal  men- 
ingeal tumors  lie  in  the  cord  like  an  egg  in  a  nest.  They 
press  upon  the  cord  slowly  but  do  not  cause  the  cord  ab- 
sorption and  may  be  enucleated  with  relief  of  all  symptoms 
sometimes. 

Tumors  external  to  the  dura  do  not  immediately  disturb 
the  cord  functions  for  obvious  reasons,  connected  with  what 


291 

we  know  of  the  cerebro- spinal  fluid  and  the  floating  of  the 
cord  in  the  spinal  canal.  The  favorite  seat  of  cord  tumors 
is  dorsal  and  caudal. 

The  circulation  of  the  cord  will  engage  your  study  in 
connection  with  congestion  or  hyperaemia  and  a  diminished 
blood  supply  or  anaemia  of  the  cord  or  spinal  irritation. 
The  circulation  is  also  involved  in  inflammation  of  the  envel- 
oping membranes  or  meningitis  and  in  inflammation  across 
the  cord  or  myelitis,  the  columns  and  horns  of  the  cord, 
will  interest  you  in  spinal  paralysis  and  spasmodic 
states  like  tetanus  and  the  scleroses,  lateral  spastic,  and 
posterior. 

The  arteries  of  the  cord  are  first  the  anterior  spinal 
arteries,  which  commence  at  the  medulla  oblongata,  branch- 
ing from  the  vertebral  of  each  side  and  running  down  the 
middle  of  the  front  of  the  cord.  Other  branches  are  de- 
rived from  the  vertebral,  ascending  cervical,  intercostal  and 
lumbar  arteries,  which  pass  through  the  intervertebral  fora- 
mina, and  assist  in  keeping  up  the  size  of  this  anterior  ar- 
tery. "And  the  posterior  spinal  arteries  which  come  also 
from  the  same  source,  vertebral,  intercostal  and  lumbar  ar- 
teries, ramify  irregularly  over  the  back  of  the  cord." 

"The  spinal  arteries  of  the  opposite  sides  communicate 
by  numerous  transverse  branches  along  the  entire  length  of 
the  spine"  on  the  anterior  part  of  the  bodies  of  the  verte- 
brae, "thus  resembling  the  arrangement  of  the  venous 
plexuses  of  the  cord."  Accompanying  are  illustrations  of 
the  cord's  circulation.  The  venous  from  Holden  (Figs.  141 
and  142)  and  the  arterial  from  Brissaud  (Fig.  143)  and  by 
Gowers  (Fig.  144),  the  latter  modified  by  Church  (Fig.  145). 

Our  modern  anatomists,  those  painstaking  followers  of 
the  great  Vesalius,  who  made  the  first  human  dissect- 
ion, who  by  their  clear  delineations  of  the  spinal    cord  and 


292 


its  relations  to  the  spinal  canal  and  the  vertebrae  that  con- 
tribute .to  make  this  remarkable  nerve  center  channel  of 
protection  and  conduction,  have  enabled  us  to  understand 
intelligently  the  remarkable  power  of  resistance  of  the  cord 
and  its  membranes  to  ordinary  movements  and  lighter  in- 
juries of  the  spinal  column  and  even  to  what  would  other- 
wise prove  to  be  very  considerable  shocks  to  the  delicate 
structures  of  the  cord. 

FIG.   141. 


ACBAM.OE.THF. 


SPINAL  VE1KS.      (VERTICAL  SECTION.) 


Z,.  PoT6i-6|>vwcxX\e\'cvs. 
VSp'vtt«iX  ve'vtvo. 


The  arrangement  of  the  cord  within  the  spinal  canal, 
floating  as  it  were,  like  an  anatomical  or  pathological 
specimen  suspended  from  the  neck  of  a  bottle,  immersed  in 
a  sack  of  fluid,  enables  the  cord  to  swish  a  little  back  and 
forth  and  from  side  to  side  without  having  its  function  de- 
stroyed. The  dentate  ligaments,  as  seen  in  the  accom- 
panying illustration  and  the  loose  relation  of  the  dura  of  the 
cord  to  the  cord  and  canal  walls  and  cushioning  veins,  also 
here  shown  in  these  drawings  from  nature  of  the  cord's  cir- 
culation, make  plain  still  farther  Nature's  kind  conservation 
of  the  cord  against  ordinary  violence. 


293 

A  concussion  of  the  cord  at  either  side,  as  from  a  sud- 
den or  violent  fall  on  the  head  or  on  the  ischial  and  sacral 
bones,  would  disturb  the  cerebro-spinal  fluid  from  one  end 
to  the  other  and  give  the  delicate  neurones  of  the  cord  cen- 
ters and  their  prolongating  neuraxone  or  dendrite  connect- 
ions, into  the  motor  or  sensory  nerves,  a  comparatively  less 
delicate  shock   than  they  now  receive  under  Nature's   kind 

fig.  142. 


DIAGRAM   OF  THE  SPINAL  VEINS.      (TRANSVERSE  SECTION.) 

&     T^c-y-AA/-  /O^a^vvoJL'     \t€a^v^^  . 


protecting  anatomical  safeguard.  1  say  comparatively  deli- 
cate shock,  because  of  the  water  wall  of  the  cerebro-spinal 
fluid  and  attachment  of  the  dentate  bodies  of  at  least 
twenty  of  the  spinal  cord  segments  of  the  cord  and  extend- 
ing the  cord's  entire  length.  Injury  to  the  cord  from  vio- 
lence is  often  therefore  slight  and  microscopic,  compared  to 
what  it  might  be   from  the    same  degree    of   violence,  were 


294 

it  not  for  this  wonderful  conservative  arrangement  of  this 
most  delicate  and  important  structure,  which  condenses  ca- 
pacity for  so  much  power  and  force  of  function  in  so  little 
space.  Nature  here,  as  so  often  elsewhere  in  the  human 
framework,  is  preeminently  wise  and  kind  to  man  in  her 
wondrous  adjustments  of  structure  and  function.  Extreme 
delicacy    of     texture,    greatness     in     nerve     force,    engen- 

FIG.   143. 


Kin.  circulation 

in  oord  BegmenfcMDu  iii   vi-illL-al  directions 
(Rrissaud).  ©<J^£»>CfV©»%V&- 


dering  capacity  and  marvelously  strong  protective  ar- 
rangements make  up  Nature's  marvelous  mechanism  as 
displayed  in  her  building,  bounding  and  locating  of  the 
spinal  cord.  It  can  be  damaged  by  great  concussion, 
but  not  by  the  slight  jars  and  disturbances  of  ordi- 
nary human  movements.  It  takes  extraordinary  violence 
to    harm    it,  like    falls    from    heights,  inadvertent    stepping 


295 

downward  to  an  uncalculated  depth  or  the  momentum  of  a 
railway  train  suddenly  stopping  or  a  head-end  collision,  or 
the  sudden  drop  of  an  elevator  or  the  violent  jerk  of  it,  or  a 
ponderous  street  car's  too  suddenly  checked  momentum. 

fig.  144. 


AfcS 


—Semi-diagrammatic  representation  of  the 
arteries  of  the  spinal  cord ;  A  s,  anterior  spinal. 
Central  arteries. — A  M,  anterior  medial ;  c  a,  be- 
tween the  right  and  left  commissural  arteries; 
a,  anastomotic  artery,  divided  transversely,  to 
which  a  branch  goes  from  the  commissural  artery, 
which  then  divides  into  a  c,  anterior  cornual,  and 
m  c,  mid-cornual  arteries.  Peripheral  arteries. — 
p  m,  po-terior  medial ;  p  i,  post- intermediate  ;  p  c, 
posterior  cornual;  p  r,  posterior  radicular;  p  I, 
m  I,  a  I,  regions  of  the  posterior,  middle,  and 
anterior  lateral  l>ranches ;  ar,  anterior  radicular. 
In  the  rght  half  of  the  figure  the  more  deeply 
shaded  part  indicates  the  region  supplied  by  the 
central  arteries.  £0u£teT  \fO VW^C  S) 


One  of  the  problems  for  you  to  work  out,  is  why  an 
inadvertent  previously  uncalculated  step  into  mentally  unmeas- 
ured depth,  even  though  slight,  should  harm  the  cord,  when 
the  same  step  anticipated  does  not.  Does  the  will  regulate  the 
flow  of  the  cerebro- spinal  fluid  to  protect  the  cord  against 
effects  of  the  concussion,  or  what  does  take  place?      What 


296 

help  do  the  intervertebral    cartilages  give,  and  how?     Does 

the  will >  regulate  these  as  it  Joes  the  muscular  tension  of 
the  back  muscles?  Is  there  something  like  a  vasomotor 
mechanism  for  the  cerebro- spinal  fluid  channels?  Work 
this  problem  out  in  your  minds  and  tell  me  what  you 
think  about  it  at  our  next  meeting,  or  later  in  the  med- 
ical   press. 

The    true    nature  of    the   tumors   of    the    interior  of  the 
cord  is  generally  best  diagnosticated  post-mortem.     We  de- 

FIG.  145. 


trteriea  of  the  Bpinal  cord.    A  S,  Anterior  spinal ;  A  -V,  anterior  median ;  re,  commia- 
u,  uuastoniotic ;  a e,  anterior  contra! ; />,  posterior  central ;  a r, anterior  root  arteries ;  a/,  anterior 

lateral;  m/,  median  lateral ;  p /,  posterior  lateral:  jj  r,  postcrloi   I  artery;  pc,  postcrjoi   con 

intermedial"  .  i.ial ;  p m,  iiosterlor  median  Oliersteinei      by  Cku/GcA  ) 


tect  their  existence  through  unilateral  or  bilateral  neuralgic 
symptoms  and  circumscribed  hyperesthesias  encircling  the 
trunk  hemiplegias,  monoplegias,  paraplegias  or,  if  in  the  neck 
regions,  general  paralysis.  Irritation  at  the  posterior  spinal 
nerve  roots  causes  pain  usually  unilateral,  because  tumors 
are  generally  one-sided,  at  least  in  the  beginning  of  their 
development.  Besides  pain,  their  extreme  pressure  causes 
belt  lines  or  half  belt  lines  of  anaesthesia.     Motor  weakness 


297 

sets  in  and  later  spinal  paralysis  and  spastic  states    appear 
and  bladder  and  rectum  functions  are   affected. 

The  spinal  cord,  only  from  sixteen  to  eighteen  inches 
in  length  in  man,  and  a  little  shorter  in  woman,  weighing 
about  an  ounce  and  suspended  in  the  vertebral  canal  down 
to  the  second  lumbar  vertebra,  with  a  swing  movement  in 
the  spinal  canal  of  from  a  half  to  three  quarters  of  an 
inch,  or  a  little  more,  is  a  source  of  remarkable  power  in 
health,  a  power  greater  than  any  mechanism  of  man's  contriv  - 
ance  of  many  times  its  size  and  weight.  It  is  also  subject 
to  very  remarkable  diseases.  Like  the  brain,  the  cord's 
inflammatory  diseases  are  congestive,  anaemic,  adventitious, 
hernial  profusions,  degenerative  states,  tumors,  specific  dis- 
ease, like  tuberculosis  and  syphilis  or  toxic  disease,  like 
tetanus  and  functional  states,  like  neurasthenia,  and  the 
secondary  conditions  of  its  inflammations  classical  in  the 
sclerosis  and  softenings,  degenerative  states  of  the  cord, 
like  the  ataxias  or  scleroses,  posterior  or  disseminated. 

The  meninges  of  the  spinal  cord,  like  those  of  the 
brain,  are  liable  to  pachymeningitis,  hemorrhagic  and  hyper- 
trophic pachymeningitis  and  the  pia  mater  to  leptomeningitis. 
The  substance  of  the  cord  is  subject  to  myelitis  and  syrin- 
gomyelia, as  the    brain  is  to  porencephaly  and  cerebritis. 

The  circulation  of  the  cord  suffers,  like  that  of  the  brain, 
from  embolism,  thrombosis,  hemorrhage,  plus  and  minus 
blood  supply  states,  and  the  cord  is  subject  to  disorder  from 
injury  or  deficiency  of  its  incasing  vertebrae,  as  in  Pott's 
disease  or  spina  bifida. 


298 


THE  SPINAL  CORD,   AFTHR  QUA1N  AND   FERRIER 
FIG.   146. 


In  A  the  anterior  surface  of  the  cord  is  shown.  The  anterior  nerve  root 
being  divided  on  the  right.  In  B  a  transverse  section  of  the  cord  is  exhibit- 
ed, showing  the  crescentic  shape  of  the  grey  matter  in  the  interior.  1,  The 
median  anterior  fissure.  2,  Posterior  median  fissure.  3,  Anterior  lateral 
depression  over  which  the  anterior  nerve  roots  are  seen  to  spread.  4,  Pos- 
terior lateral  groove  into  which  the  posterior  roots  are  seen  to  sink. 

The  anterior  column  is  included  between  1  and  3;  the  lateral  column 
between  3  and  4;  and  the  posterior  column  between  4  and  2. 

5,  The  anterior  root.  5'  in  A  equals  the  root  divided.  6,  The  posterior 
roots,  the  fibers  of  which  pass  into  the  ganglion  6'.  7,  The  united  or  com- 
pound nerve. 


299 


FIG.   147. 


Section  of  the  spinal  cord  after  Ferrier,  in  the  lumbar  region,  magnified. 
— A,  The  anterior  column.  L,  The  lateral  column.  P,  Posterior  column. 
1,  The  anterior  fissure.  2,  The  posterior  fissure.  3,  The  anterior  cornu 
with  multipolar  cells.  4,  Posterior  cornu  the  letters  placed  on  the  sub- 
stantia gelatinosa.  5,  The  anterior  roots  of  the  spinal  nerve.  6,  The 
posterior  roots.  7,  The  anterior  commissure.  8, The  posterior  commissure. 
9,  The  central  canal  of  the  spinal  cord  lined  with  epithelium. 


300 


FIG.   148. 


.  *  ?ot\Xtle&.?v&artce 


'olumn  tflissauer 


(SAjJL  fyx-v^^'v  o.j 


I  smnal  cord;  allowing  its  anatomical  Mihil i  visions  (S, lined.! 


CHAPTER    XXVI. 

NERVE    CENTERS    (CONTINUED). 


PSYCHO-MOTOR  CENTERS— VISUAL  APPARATUS  CENTERS— OTHER  MO- 
TOR AND   REFLEX  CENTERS. 

Nerve  centers  are  somewhat  shadily  circumscribed  re- 
gions in  the  nervous  system  made  up  of  groups  of  neurones, 
as  we  have  seen  in  a  previous  lecture,  having  a  common 
function,  to  which  concentric  or  afferent  nerve  influences 
travel  or  converge  and  may  be  there  acted  upon  by  the 
nerve  center  and  from  which  efferent  or  eccentric  impres- 
ions  emerge  or  are  sent  out.  If  the  peripheral  impression 
going  to  a  nerve  center  is  simply  transmitted  into  a  motion 
or  pain  or  other  sensation  and  sent  back  to  the  point  from 
which  the  afferent  or  peripheral  impression  originated  or 
started  or  to  .some  related  peripheral  organ,  the  action  is 
called  a  reflex  action,  as  when  a  smart  tap  below  the  knee 
sends  up  an  impression  afferently  to  the  posterior  col- 
umns of  the  spinal  cord,  then  goes  across  the  cord  to  the 
anterior  motor  poles  or  horns  or  cornua  of  the  cord  and 
comes  back  (efferently)  to  the  knee  again,  as  a  motor  im- 
pulse, making  the  classical  knee  jerk  or  knee  phenomenon 
in  healthy  states  of  the  posterior  root  zones  of  the  cord, 
but  which  can  not  be  elicited  in  posterior  spinal  sclerosis 
or  locomotor  ataxia  and  in  that  suddenly  oncoming  disease 
of    the  anterior  horns  called  poliomyelitis,  anterior  or  infan- 

[301] 


302 

tile  paralysis,  or  the  essential  paralysis  of  children,  and 
which  is  also  absent  in  a  similar  condition  of  the  anterior 
horns  of  the  cord  in  adults. 

The  reflexes  are  all  over  the  body.  The  eye  has  its 
reflexes,  as  when  a  grain  of  dirt  impinges  on  the  eyeball 
and  the  eyelids  wink  till  it  is  removed,  or  as  they  wink 
when  we  tap  the  supraorbital  or  infraorbital  region  over 
their  respective  nerves  of  the  fifth  pair  emerging  from  the 
superior  or  inferior  orbital  foraminae. 

The  nose  has  its  reflexes  or  reflex  starting  points,  as  in 
sneezing,  which  is  a  medulla  reflex,  and  there  is  a  peculiar 
reflex  or  rather  transmitted  impression  which  runs  over 
the  body  in  some  people  when  the  external  canal  of  the  ear 
is  tickled.  The  larynx  and  pharynx  have  their  reflexes,  as 
when  coughing  or  swallowing  are  excited,  the  stomach  as  in 
vomiting,  the  bladder  in  urination,  the  rectum  in  defecation, 
the  bowels  in  peristalsis,  the  genitals,  the  chest,  the  plantar 
region,  the  toe,  the  sole  of  the  foot  and  so  on.  These  re- 
flexes are  really  nerve  center  reflexes  only  manifested  in 
these  localities.  But  we  shall  recur  to  them  again  and 
more  in  anatomic  and  diagnostic  detail. 

When  a  nerve  impression  is  not  transformed  and  sent 
back  in  motion  or  reflected  in  pain,  it  is  often  transmitted 
further  along  or  higher  up  the  cerebro-spinal  axis,  it  is 
called  a  transmitted  impression  and  a  good  deal  of  what  is 
often  inconsistently  called  reflex  action  is  really  of  this  na- 
ture. True  reflex  action  is  usually  sensation  transformed  into 
motion  and  sometimes  pain  with  it,  and  sent  back  to  the 
point  of  origin  of  sensation  or  near  to  it.  Other  varieties 
of  what  has  been  loosely  called  reflex  action  are  really 
transmitted  or  sent  on  impressions,  exciting  action  in  some 
other  point  or  nerve  center.  There  is  probably  not  so  much 
pure  reflex  action  in  nervous  disease  as  has  been  supposed, 


303 

but  a  good  deal  more  of  transmitted  nerve  center  action 
dependent  on  physiological  nervous  connections  made  to 
act  morbidly  and  reveal  disease  by  reason  of  intimate,  though 
sometimes  distant,  nervous  relations  as  you  may  see,  and 
study  with  diagnostic  and  therapeutic  profit  in  the  pain  point 
tables  and  pain  transmission  of  your  text-books,  notably, 
in  the  instructive  table  of  Dr.  Allan  M.  Starr  and  Mills. 

In  addition  to  the  psychic  and  sympathetic  system  cen- 
ters, the  centers  of  the  nervous  system  are  designated  sen- 
sory centers,  for  the  reception  of  sensation,  motor  centers 
for  the  sending  out  of  impulses.  Reflex  centers  at  the  top 
of  the  reflex  arc  where  sensory  impressions  are  converted 
into  motor  impulse  or  expression,  inhibitory  centers  which 
inhibit  or  arrest  or  prevent  action  that  would  otherwise  be 
pure  reflex  movement.  Motor  centers  are  either  spinal  mo- 
tor or  brain  motor,  that  is,  psycho-motor  or  cortical  motor 
centers.  The  most  important  motor  centers  are  the  corti  - 
cal,  as  they  are  also  anatomically  located  highest  in  the  cer- 
ebrospinal axis. 

Cortical  centers  are  gray  matter  brain  centers.  They 
are  called  cortical  motor  centers  or  psycho-motor  centers, 
because  impulses  to  direct  movement  originate  there,  and 
psychic  impression  centers  because  voluntary  movement 
thought,  originates  in  them  or  rather  starts  from  them.  Im- 
pressions go  to  these  psychic  centers  from  without  the  brain, 
principally  through  the  nerves  of  special  sense  as  those  of 
smell,  taste,  sight,  hearing.  Special  touch  and  general  sen- 
sation and  impression  pass  up  to  them  through  and  from 
the  periphery  and  posterior  columns  of  the  spinal  cord  and 
through  the  optic  thalami,  as  the  latter  go  to  the  spinal 
cord  from  the  surface  of  the  body. 

The  motor  centers  of  the  brain,  called  psycho-motor  cen- 
ters, are  mostly  l'ocated  and  grouped  about  either  side  of  the 


304 

fissure  of  Rolando,  in  the  ascending  parietal,  the  ascending 
frontal- convolution  and  the  third  frontal  convolution  or  speech 
center  of  Broca,  the  location  of  aphasia.  Impulses  from  them 
outward  from  the  corona  radiata  or  project  in  fibers  down- 
ward through  the  crura  cerebri  and  pyramidal  tracts  and 
antero-lateral  columns  of  the  spinal  cord. 

The  auditory  center  or  cortical  sensory  center  for  the 
conscious  reception  and  discrimination  of  sounds  is  in  the 
superior  temporal    convolution    below  the  fissure  of    Sylvius 

ither  side,  but  probably  more  active  in  the  left  side  like 
the  speech  centers,  in  right-handed  persons,  the  left 
hemisphere  with  such  persons  being  the  specially  active  or 
driving  side  as  Ferrier  called  it.  Several  subordinate  dis- 
tinct or  subsidiary  centers  are  supposed  to  make  up  the  au- 
ditory center,  but  you  need  not  puzzle  your  brains  with  this 
matter  just  now.  Remember  that  the  hearing  center,  with 
alliits  real  or  fancied  subdivisions  is  located  in  the  temporal 
region. 

The  final  termination  of  visual  impression  is  in  the  oc- 
cipital lobes.  Visual  fibers  of  the  optic  nerves  and  optic 
nerve  tracts  conveying  visual  impression  go  to  the  lateral 
geniculate  bodies,  the  anterior  corpora  quadrigemina,  the 
pulvinar  of  the  optic  thalami,  and  the  angular  gyrus  or  pli 
courbe  and  are  distributed  over  a  great  part  of  the  occipi- 
tal lobes.  Their  whole  area  appears  to  be  full  of  light,  as 
Munk's  slicing  experiments  on  dogs  have  shown  where  the 
optic  apparatus  is  normal  in  structure  and  function.  The  vis- 
ual center  is  more  definitely  located  in  the  left  cuneus,  lin- 
gual and  fusiform  lobules  and  the  angular  gyrus  for  the  ap- 
preciation of  external  objects,  but  1  think'  the  side  of  the 
brain  depends  on  the  matter  of  use.  We  may  be  ambiauditory 
as  we  are  ambivisual  and  as  we  may  be  ambidextrous. 
Witness  the    once  clumsy  but    now  dextrous  violinist,  who, 


305 

after  training,  like  Ole  Bull,  Kubelik  and  other  skilled  per- 
formers, make  the  world  marvel  at  the  skill  of  their  hands 
in  delicacy  of  touch.  Equal  nucleal,  though  latent,  central 
possibilities,  are  in  the  right  side  of  the  brain,  as  well  as 
in  the  left.     Our  brains,  as  yet,  are  only    partly    educated. 

There  is  a  distinct  auditory,  as  well  as  visual  word 
center,  by  which  neurologists  account  for  some  of  the  va- 
rieties of  aphasia,  by  which  word  symbols  are  understood 
and  word  sounds  are  not  and  vice  versa  by  the  aphasiac 
person.  The  olfactory  center  has  been  located  in  the  un- 
cinate gyrus,  but  the  sense  of  smell  may  be  impaired  or 
destroyed  and  anosmia  may  be  produced  by  injury  or  disease 
at  any  of  the  origins  of  the  olfactory  nerve  or  along  its 
course  anteriorly  or  at  its  middle  turbinate  bone  point  of 
distribution  as  in  oezoena.  Hyperosmia,  that  olfactory  su- 
persensitiveness,  which  exists  sometimes  in  hysteria  and 
other  nervous  diseases  and  which  Alexander  Pope  may  have 
had  in  mind  when  he  referred  to  the  possibility  of  one  dy- 
ing of  a  rose  in  aromatic  pain,  may  depend  upon  hyper- 
excitation  along  the  distinctive  course  or  at  the  brain 
origin  of  this  nerve,  as  from  a  tumor  impinging  upon  or  a 
cerebritis  or  inordinate  activity. 

Grouped  within  the  medulla  oblongata,  not  far  from  the 
fourth  ventricle,  which  seems  to  have  been  assigned  the 
duty  by  Dame  Nature  of  providing  resident  centers  for  most 
of  the  cranial  nerves,  is  located  a  whole  colony  of  vital 
nerve  centers.  We  marvel  at  the  centers  of  power  and  in- 
fluence concentrated  in  the  fourth  ventricle.  We  wonder 
even  more  at  the  number  and  strength  of  the  nerve  centers 
of  the  medulla.  This  subject  surprises  us  quite  as  much 
as  the  nerve  force  and  influence  carrying  capacity  of  that 
little  band  of  nerve  strands  collected  and  compressed,  and 
carrying  down  from  the  brain  through  the  internal   capsules 


306 

of  the  corpus  striatum.  This  little  streak  of  strands  and 
bundle,  of  nerves  that  carries  the  supreme  power  of  the  cer- 
ebral cortex  down  to  the  lower  centers  of  the  spinal  cord 
and  sends  it  out  in  channels  of  expression  over  motor  tracts 
and  the  nerves  to  the  muscular  system,  viscera  and  outside 
world  is  a  marvel  of  force  conduction  and  the  ponto-med- 
ullary  region  is  a  marvel  of  force  generation. 

Respiration,  sweating,  swallowing,  coughing,  vomiting, 
sneezing,  bowel  peristalsis,  cardiac  inhibition  and  arteriole 
blood  vessel  tonicity  and  vaso- motor  centers  all  have  their 
seat  and  centers  in  the  medulla.  The  latter  in  the  me- 
dulla and  cord  and  some  one  has  imposed  vaso-motor  func- 
tion on  the  little  tuber  cinereum. 

The  tuber  cinereum  has  also  been  charged  with  being 
the  fons  et  origo  of  the  dog's  panting  and  the  seat  of  our 
own  pants,  as  it  were,  when  we  are  physically  overwrought 
or  overrun  or  rapidly  overworked.  The  thermotaxic  or  heat 
generating  centers  were  well  placed  in  the  medulla  by  our 
investigator,  Isaac  Ott,  and  by  foreign  neurophysiologists, 
among  the  latter,  notably,  Schiff,  Owsjaniskow  and  Leigois. 

To  the  caudate  nucleus  of  the  striate  body  has  also 
been  assigned  heat  centers  and  the  general  sensibility  per- 
ception center  has  also  been  placed  in  another  part  of  the 
.)wer  portion  of  the  corpora  striata.  The  thermo-inhibitoiy 
or  heat  controlling  centers  have  been  conjecturally,  but  not 
very  definitely,  located  in  the  fissure  of  Silvius  and  the  tu- 
ber cinereum,  and  the  thermolytic  or  heat  dissipating  center 
has  been  placed  there  also.  But  you  need  only  remember 
for  the  present  that  somewhere  in  the  gray  matter  of  the 
brain  part  of  the  cerebro-spinal  axis,  are  heat  generating 
and  heat  controlling  regulating  centers,  the  former  in  the 
medulla,  especially. 

1  think  a  good  deal  of  work  has  been  assigned  by    the 


307 

physiologists  to  the  tuber  cinereum,  but  very  small  centers 
in  the  neuraxis  do  a  large  amount  of  work.  Every  part  of 
the  gray  matter  of  the  brain,  however,  has  something  im- 
portant to  do.  Its  neurones  are  aggregated  into  working 
communities.  They  are  centers  of  action  and  power.  The 
only  part  of  the  brain  which  seems  to  have  gone  out  of 
business  since  Descartes  assigned  to  it  the  regal  seat  of  the 
soul,  is  the  pineal  gland.  This  pine  cone  shaped  attach- 
ment of  the  anterior  twins  of  the  corpora  quadrigemina  is 
waiting  for  a  new  physiological  discovery.  It  may  be  for 
one  of  you.  Descartes  is  dead.  There  are  also  to  be  con- 
sidered as  specially  important  in  diagnosis  and  treatment, 
the  cerebral  and  spinal  pupillary  centers  already  alluded  to. 
The  genital,  vesical,  anal  and  parturient  reflex  centers  and 
contraction  power  are  all  in  the  lumbar  cord.  A  wonderful 
mechanism  you  see,  is  the  nervous  system,  and  the  wonder 
of  all  this  wondrous  organism  is  the  nerve  centers  of  the 
cerebro-spinal  axis  or  neuraxis.  It  is  little  wonder  that  the 
cord  enlarges  in  the  lumbar  region  to  do  all  of  this  won- 
derful work.  It  has  a  big  job  on  hand  and  a  steady  one. 
When  its  special  centers  cease  their  vigilance  and  go  to 
sleep  or  die  from  paralysis,  there  comes  a  trying  ordeal  for 
the  poor  patient  and  for  the  attending  physician  and  the 
trained  nurse,  the  rectum  and  bladder  neglect  their  busi- 
ness, the  urine  is  retained  or  dribbles  away,  faeces  escape 
and  the  undertaker  waits  his  turn  close  at  hand.  The  fear- 
ful fatal  sequel  of  extensive  transverse  myelitis  or  complete 
across  inflammation  of  the  spinal  marrow,  which  more  often 
than  otherwise  is  caused  by  profound  injuries  to  the  back, 
when  the  back  is  broken  for  instance,  gives  us  a  pitiable 
spectacle  of  the  helplessness  of  man,  when  the  spinal  cen- 
ters have  lost  control  over  the  pelvic  viscera. 


CHAPTER    XXVII. 


THE  SENSORI-MOTOR    SYSTEM    IN   DIAGNOSIS— THE   REFLEXES. 


Bioplasm  is  all  about  us  in  animated  organism  respond- 
ing in  reflex  action,  to  the  impression  of  environment  and 
the  unanswered  question,  which  it  suggests,  "what  is  life?" 
recurs  to  us  as  it  did  to  Pilate  and  the  philosophers  of  old. 
Lional  Beall,  applying  the  term  bioplasm  of  life  to  the  pro- 
toplasm through  which  animate  movements  appear  to  us, 
has  not  answered  the  question  to  the  satisfaction  of  the 
scientific  world.  Will  you  in  your  studies  of  neuro- biology, 
endeavor  to  solve  it  for  the  enlightenment  of  mankind  and 
the  satisfaction  of  the  soul's  longing  for  clearer  light  on 
the  subject?     Man  still  asks  the  question. 

The  great  law  of  nerve  reflex  action  responsive  to  per- 
ipheral impression,  that  transforms  the  knee-tap  below  the 
patella,  for  example,  into  a  knee-jerk;  that  causes  response 
with  a  gentle  inspiration  to  the  presence  in  the  bronchi  and 
pulmonary  air  cells  of  a  congenial  breath  of  air  and  an  ex- 
piration to  the  presence  of  carbonic  acid,  generated  by  the 
pulmonary  air  change,  or  in  cough  or  spasm  to  an  uncon- 
genial breeze,  or  gas  or  other  irritation;  that  makes  the 
sneeze  similarly  responsive,  or  the  strangling  effort  at  ex- 
pulsion of  food  or  water  going  down  the  wrong  way,  into 
the  trachea  instead  of  the  gullet;  that  moves  the  bowels 
or  bladder  or  regulates  the  sphincter;     that  causes  the  face 

[303] 


309 

to  smile  with  joy  or  mantles  it  witli  sadness,  responsive  to 
a  voice  or  written  word;  that  makes  the  pupil  move  to 
light  or  to  the  withdrawal  of  light  in  darkness;  that  moves 
the  eyelids,  lights  or  dims,  moistens  or  drys  the  eyes; 
blanches  the  cheek  with  fear  or  suffuses  them  with 
blushes;  gives  the  fierce  glare  of  anger  or  the  expressions 
of  vengeance,  despair  or  hope;  that  causes  weeping,  laugh- 
ter or  tears  and  all  the  different  facial  expressions  of  the 
varying    moods    and    emotions    of    the  mind.     That  makes 

"Soft  eyes  look  love  to  eyes  that  speak  again," 

reflecting  love  in  smiles  of  reciprocal  joy;  that  show  sad- 
ness in  tears,  joy  in  mirthful  laughter  and  shame  in  the 
downcast  look,  are   all  psycho-neural  reflex  phenomena. 

Psychic  reflection  flashes  back  the  wit  responsive  to 
other  psychic  impression  that  is  "wont  to  set  the  table  in 
a  roar."  It  tunes  the  voice  of  the  warbling  nightingale  and 
excites  response,  in  the  human  brain  and  related  vocal  cords 
to  spellbinding  oratory,  swaying  the  multitude,  or  to 
Poesy's  enraptured  song,  flying  on  the  wings  of  Pegasus,  far 
beyond  the  ordinary  psychic  dwelling  places  of  man.  Even 
the  value  of  the  bath  Diana  takes  at  the  fountain,  besides 
its  purification  of  the  skin,  which  fills  her  body  with  the  glow 
of  health,  comes  through  a  vaso- motor  reflex  blush  of  the 
cutaneous  capillaries  and  nervous  internal  stimulation. 

Poesy,  song,  oratory  and  the  entrancing  influence  of 
truth  and  the  wondrous  power  and  revelations  of  science 
are  shown  in  the  full  knowledge  of  the  physiological  signifi- 
cance of  reflex  function.  As  this  knowledge  has  come  and 
is  yet  further  coming  to  us,  it  is  bringing  us  nearer  and 
nearer  to  that  knowledge  which  is  yet  to  reveal  the  still 
concealed  mysteries  of  organic  life. 

And  our  friends,  the  great,  studious,  painstaking  cytolo* 


310 

and  cyto-chemists  and  indefatigable  microscopists 
will  yet  show  to  us  through  their  great  labors  and  re- 
searches, the  full  truth,  not  dimly  and  darkly,  as  we  now 
see,  as  through  an  obscuring  glass,  but  in  the  full  glare  of 
the  coming  sunshine  of  an  onmarching  cytological,  neurolog- 
ical and  psychological  science. 

Study  the  reflexes  of  organic  life  so  far  as  they  are 
now  revealed  and  search  further  for  others.  The  final  rev- 
elation of  the  now  hidden  mysteries  of  life  are  the  possi- 
bilities of  their  unfolding  knowledge.  It  brings  the  sper- 
matozoa and  the  ova  together  in  the  consummation  of  "two 
souls  with  but  a  single  thought,  two  hearts  that  beat  as 
one"  and  by  it  new  lives  are  born.  It  presides  over  the 
quickening  of  the  unborn  foetus  in  utero  and  causes  the 
child  to  begin  its  later  search  for  the  pabulum  of  life  in 
the  lacteal  fluid  of  the  generous  mammary  gland  of  the 
mother.  When  evolution  is  complete  at  puberty  it  "causes 
the  passionate  heart  of  man  to  enter  the  breast  of  the  wild 
dreaming  boy"  and  the  mind  of  the  maiden  at  maturity  to 
fill  and  her  heart  to  throb  with  new  emotion.  It  translates 
instinct  into  function  and  heredity  into  physiological  or 
pathological  action.  The  philosophers  of  science  are  yet 
puzzled  to  find  the  boundaries  of  reflex  and  free  will,  so 
closely  allied  is  reflex  with  apparent  will  power.  "The 
chemical  stimulation  of  food  in  the  mouth  will  in  certain 
animals    set    the    jaws  and  mouth  into  masticatory  action." 

A  bee's  mouth  will  suck  honey  after  its  head  has  been 
cut  from  the  body.  "Other  stimulations"  notes  Edinger 
"will  cause  a  forward  movement  of  the  head  and  such  move- 
ment can  be  of  sufficient  force  to  lead  to  very  serious  re- 
sults. Thus  a  planaria  on  which  two  heads  have  been 
bred  will  sometimes  tear  its  own  body  in  the  effort  of  mov- 
ing each  head  separately."     (Loeb).     Two    arms  of    a  star 


311 

fish  sqjsezed  into  the  small  neck  of  a  bottle,  will  drag  the 
whole  body  after  them,  although  the  creature  must  inevi- 
tably perish.  The  head  part  of  the  lob-worm,  separated 
from  the  body  and  covered  with  sand  on  the  slate,  will 
immediately  start  a  boring  movement,  and  the  lower  part 
of  a  bee  when  cut  from  the  rest  of  the  body  will  apply  the 
sting,  if  interfered  with.  This  is  evidently  the  mechanical 
result  of  a  particular  stimulation  and  has  nothing  in  com- 
mon with  anger,  vengeance,  venom  or  self-defense. 

"It  is  a  well-known  fact  that  frogs  couple  in  the  spring 
time  and  no  knife  can  part  them."  Earlier  experiments  by 
Golz  have  shown  that  at  the  coupling  time  the  skin  of  the 
female  and  even  that  of  the  male,  even  though  they  be 
dead,  if  stuffed  with  ova,  gives  rise  to  the  reflex  action  of 
embracing  as  soon  as  it  is  brought  into  contact  with  the 
inner  side  of  the  frog's  feet.  We  might  cut  up  the  frog  from 
behind  up  to  the  cervical  cord,  or  crush  it  from  the  head  down- 
ward, the  result  will  remain  the  same;  i.  e.f  the  ring  formed 
by  the  cervical  cord  and  the  two  arms,  even  when  entirely 
separated  from  the  rest  of  the  body,  will  continue  in  the 
position  and  action  of  coupling  frogs."     (Edinger). 

Search  for  and  seizing  of  food  can  be  ascribed  directly 
to  reflex  movements.  The  frog  does  not  search  for  the 
worm,  but  the  moving  worm  when  sufficiently  perceived  by 
eye  and  ear,  sets  into  motion  the  process  of  catching  it  on 
the  frog's  part.  This  can  be  easily  perceived  in  places 
where  animals  are  kept  in  a  cool  temperature,  and  pro- 
cesses run  their  courses  slowly.  The  well-known  fact  that 
lower  animals  mostly  feed  on  moving  objects,  is  thus  ex- 
plained. It  is  easy  to  deceive  them  by  setting  objects  in 
motion.  Artificial  bait  fishing  is  based  on  the  same  prin- 
ciple".* 

*Edinger   in  April  Monist,  1901. 


312 

While  independent  reflex  mechanisms  are  in  the  viscera, 
skin,  and  probably  in  the  forebrain  also,  the  medulla  and 
the  cord  below  are  preeminently  their  seat.  The  life  of 
the  spine  is  in  its  reflexes  and  much  of  all  organic  life  else- 
where in  the  cerebro-spinal  axis  is.  Gentlemen,  reflect 
well  on  the  reflexes  of  animal  life,  for  in  them  you  may 
find  much  of  the  philosophy  of  life,  and  much  to  aid  you 
in  the  intelligent  understanding  and  practice  of  your  pro- 
fession. 

Suitably  recipient  nerve  endings  receive,  and  conduct- 
ing or  afferent  nerves  carry  peripheral  impressions  to  the 
posterior  columns  of  the  cord  or  directly  to  the  brain.  If 
the  impression  goes  to  a  posterior  center  in  the  cord  and  is 
passed  over  to  the  anterior  columns  and  transforund  into 
motion  without  the  intervention  of  the  brain,  the  whole  phe- 
nomenon, sensation  and  involuntary  motion  resulting,  is 
called  a  spinal  reflex — and  these  reflexes  may  be  either  physi- 
ological (/.  e.,  natural  and  normal)  or  pathological  (i.  e.,  not 
natural  but  abnormal  to  particular  nerve  arcs).  For  exciting  a 
normal  reflex  a  sudden,  generally  a  surprise  impression  and  a 
healthy  nerve  center  are  requisite.  An  abnormal  reflex 
generally  depends  on  central  morbid  irritability  or  commenc- 
ing degeneration.  The  reflex  arc  is  the  track  of  sensation 
from  the  distal  end  of  a  sensory  nerve  to  the  cord  center, 
passed  over  across  the  cord  from  posterior  to  anterior  horns 
and  there  converted  into  sudden  movement  from  central  to 
distal  end  of  motor  nerve,  completing  the  reflex  arc. 


313 


REFLEX  AND  INHIBITORY  CENTERS. 
FIG.    149 


Scheme  of  peripheral  spinal  sensory  neurone  showing  the  peripheral 
process,  d,  extending  to  a  peripheral  sensory  surface  D  and  a  central  axone 
c,  entering  the  spinal  cord  through  the  dorsal  root  of  a  spinal  nerve,  there 
bifurcating  at  e  into  an  ascending  and  a  descending  limb  which  give  off  num- 
erous collaterals.     The  cell  body  is  shown  in  the  spinal  ganglion  G. 

Other  neurones  are  shown  schematically  high  up  in  the  gray  cortex  of 
the  brain  at  g,  to  which  the  arrow  points,  receiving  the  upward  going  peri- 
phero-spinal  sensation  and  at  A  to  a  with  the  downward  pointing  arrow 
between,  showing  the  origin  and  outflow  of  a  motor  impulse  from  a  cortex 
neurone  group  to  its  spinal  cord  ending  at  b,  and  its  final  peripheral  ex- 
pression atC.  The  whole  showing  impression  from  environing  influence 
carried  afferently  to  the  brain  and  sent  back  from  a  psycho-motor  center  to 
to  environment  again  in  active  impulse.  X  represents  the  sensory  impulse 
as  having  undergone  a  modifying  or  inhibitory  change  through  contact  with 
cortex  inhibitory  influence,  slightly  modified  in  description.  (After  Ramon 
y  Cajal,  description  modified.) 


314 

The   phenomena  of   a  reflex,  therefore,  is    a    peripheral 

sensation  transmuted  into  responsive  motion. 

Reflexes  or  jerks  have  been  divided  into  skin  or  super- 
ficial reflexes  and  tendon  or  muscle  or  deep  and  visceral  re- 
flexes  and  into  organic  or  physiological  and  pathological. 
Some  authors,  Gowers  for  instance,  do  not  consider  the 
tendon  jerks  as  true  reflexes,  hut  1  so  regard  them  and 
think-  they  are  quite  as  emphatically  entitled  to  be  consid- 
ered as  true  reflexes  as  the  skin  reflex  phenomena.  All  re- 
flexes are  dependent  on  spinal  cord  or  sympathetic  or  gang- 
lionic or  brain  central  connections,  and  1  see  no  need  of 
any  confusing  differentiation,  since  the  principle  of  their  dis- 
play is  the  same,  namely:  an  impression  made  at  one  end 
of  a  sensory  nerve  exciting  a  corresponding  motor  response 
through  a  connecting  motor  nerve  and  central  communica- 
tion. The  so-called  superficial  reflexes  are  those  of  the 
foot  (dorsal  flexion),  and  the  withdrawal  that  results  from 
tickling  or  making  a  sudden  painful  or  cold  or  hot  impres- 
sion on  the  sole  of  the  foot,  the  abdominal,  etc.  Every 
one  knows  how,  in  sleep,  the  foot  will  flex  and  the  leg 
draw  up  when  the  sleeper  is  -tickled  or  scratched  on  the 
sole  of  his  foot.  The  reflex  of  the  testicles  or  cremasteric 
reflex,  by  which  the  testicle  is  made  to  draw  up  by  pinch- 
ing or  applying  electricity  to  the  inner  side  of  the  thigh  are 
other  skin  reflexes  so-called.  They  are  organic  reflexes, 
though  not  always  so  termed  by  authors,  because  they  be- 
long physiologically  to  the  organism  in  health  like  the  knee, 
or  quadriceps  extensor  femoris  tendon  reflex,  as  it  is  some- 
times otherwise  lengthily  termed.  There  are  many  other 
organic  reflexes  which  are  active  in  health  and  impaired  in 
disease. 

The  true  organic  reflexes  are  those  which  are  necessary 
to  some  physiological  function  of  the  organism  lil-e  those  of 


315 

the  stomach  and  bowels  in  peristalsis  and  the  contractions 
that  promote  the  downward  movements  of  the  intestinal  in- 
gesta  and  excreta,  or  like  those  of  the  oesophagus  and  the 
closure  of  the  epiglottis  in  swallowing  a  drink  or  a  bolus 
of  food,  the  rhythmical  movements  of  the  lungs  and  heart, 
the  sneezing  excited  by  a  sternutatory,  the  coughing  of  a 
bronchial  irritation  or  the  blinking  of  an  irritated  eye,  (an 
Augenblick) ,  a  movement  so  rapid  and  brief  and  sure  that 
the  Germans  have  coined  this  unerring  function  into  a  most 
expressive  phrase  significant  of  celerity  and  certainty. 

The  rectal  reflex  through  which  defecation  is  per- 
formed and  by  which  the  involuntary  discharges  of  destruc- 
tive brain  and  cord  disease,  (dysentery  and  diarrhoea),  some- 
times occur  when  the  inhibitory  brain  centers  and  fibers  com- 
ing down  the  cord  from  them  in  the  brain  are  exhausted 
or  spinal  cord  communication  from  the  brain  down- 
ward is  intercepted  or  destroyed,  as  in  spinal  injury,  coma, 
some  states  of  delirium,  or  when  the  patient  is  in  articulo 
mortis  or  the  condition  of  death,  just  following  the  death 
stroke.  It  is  the  same  with  the  reflex  controlling  the  urin- 
ary excretion,  but  the  bladder  reflex  generally  contracts  the 
sphincters  under  withdrawal  of  the  cerebral  inhibitions,  ex- 
cept when  bladder  distension  is  very  great,  unless 
there  is  a  conjoint  general  convulsive  condition,  as  in  epi- 
lepsia. 

The  antagonizing  reflexes  of  the  sphincters  and  the 
bladder  fundus,  the  preponderating  weakness  of  the  one 
over  the  other  and  the  state  of  the  brain  inhibitions,  ex- 
plain the  differing  bladder  phenomena  of  urinary  retention 
or  expulsion. 

The  enuresis  of  childhood  is  a  weakening  of  bladder 
sphincter  control  reflex  conjoined  with  general  nervous  debil- 
ity, which  is  irritability,  which  causes  the  bladder  to  contract 


316 

on  its  contents  when  it  is  full  and  expel  them,  while  the 
inhibitions  are  off  guard  dining  profound  sleep.  There  are 
also  a  perineal,  genital,  genesiac,  virile  and  many  muscular 
tendon  reflexes  which  are  normal.  Others  appear  only  when 
there  is  disease. 

The  lubo-sacral  plexus  of  nerves;  the  fifth  lumbar  and 
the  first,  second,  third,  fourth  and  fifth  sacral  nerves  presides 
over  the  bladder,  rectal,  sexual,  includingthe  cremasteric  and 
virile  reflexes,  and  over  the  reflex  of  the  perineum  and  the 
quivering  nates  that  tremble  when  they  are  slapped.  Thus 
you  see  the  whole  subject  presents  interesting  aspects  to 
physiologist,  pathologist  and  clinician.  The  abdominal 
and  scapular  reflexes  are  made  possible  through  the  dorsal 
nerve  supply — sensory  and  motor — distributed  to  the  skin 
and  muscles  of  the  thorax  and  abdomen.  The  pudic  nerve, 
in  its  reflex  relations,  as  1  shall  show  you  later,  is  exceed- 
ingly important  and  likewise  the  vagus. 

The  deep  or  tendon  reflexes,  the  clonus  and  other  con- 
tractions, the  paradoxical  contraction  of  Westphal,  the  pu- 
pillary reflexes,  including  the  Argyll-Robertson  pupil,  the 
nerve  reactions  especially  of  degeneration  under  electric 
stimulation  and  the  conditions  and  terms  of  disturbed  sen- 
sibility will  engage  our  attention  again  in  subsequent  lec- 
tures. 

1  give  you  on  the  board  a  simple  schematic  diagram 
of  the  reflex  arc  with  an  imaginary  line  of  inhibitory  con- 
duction from  the  brain  to  the  center  or  the  reflex  arc.  I 
stop  here  purposely  in  order  not  to  embarrass  your  under- 
standing of  the  wonderful  phenomenon  of  reflex  which  is 
in  reality  not  quite  so  simple  as  thus  far  appears,  though, 
so  far  as  this  lecture  has  proceeded,  1  have  been  scrupu- 
lously correct. 

But  there  is  another  and  very  important  feature  to  the 


317 

physiology  of  the  spinal  reflexes  and  the  cerebral  too,  in 
fact,  which  often  has  valuable  pathological  and  diagnostic 
significance,  and  that  is  the  fact  that  the  spinal  reflex  re- 
sponses to  peripheral  irritation  are  often  exaggerated,  some- 
times very  greatly  exaggerated  by  pathological  conditions  of 
the  brain  and  spinal  cord,  as  apoplexia,  chorea,  anterolat- 
eral sclerosis,  the  late  state  of  the  epileptic  paroxysm,  hys- 
teria, neurasthenia  and  emotional  and  debilitated  states  of 
the  brain,  which  goes  to  confirm  the  view  that  there  are 
also  downward  conducting  nerve  paths  from  the  brain  which 
serve  to  intensify  the  spinal  reflexes  as  well  as  those  which 
serve  to  restrain  them,  so  that  as  the  reflexes  are  said  to 
be  reinforced  or  exaggerated  by  restraining  or  diverting  the 
cerebral  inhibitions,  they  are  also  intensified  by  certain  ex- 
citable states  of  the  brain  as  well  as  the  cord.  In  that  para- 
doxical disease,  hysteria,  so  much  like  the  sex  in  which  it 
is    most    frequently  manifest,  when    they    are    neuropathic, 

"Variable  as  the  shade 
By  the  light  quivering  aspen  made," 

you  will  find  many  reflex  contradictions;  intensification 
in  one  direction  and  impairment  or  lost  reflex  in  another. 
Intense  feeling  in  one  side  and  lost  sensation  in  another, 
just  as  alternating  psychical  states  rapidly  succeed  one 
another,  as  shown  in  the  weeping  that  succeeds  laughter 
and  vice  versa  during  a  paroxysm.  So  that  we  must  now 
make  another  diagram  in  order  to  be  perfectly  plain  on  this 
subject. 

The  emotions  which  give  rise  to  erectio  penilis  or  which 
stimulate  the  bulbo-cavernous  or  virile  reflex  center  in  the 
cord  from  the  brain  cortex,  restraining  or  causing  urinary 
ejaculation  and  defecation  or  the  voluntary  influence,  which 
increases  as  well  as  resists  them,  are  confirmatory    of  rein- 


318 

forcing  influences  and  communications  with  spinal  reflex 
centers.  Education  is  the  upbuilding  and  culture  of  the  in- 
hibiting neurones  of  the  cortex  that  regulate  the  lower  re- 
tlex  :\\\J  m  )tor  neurone  centers  of  the   brain    and  cord. 

There  are  many  important  reflexes  not  yet  recorded. 
The  virile  is  one  which  1  have  recently  recorded  in  the  lit- 
erature and  the  lately  recorded  bulbo-cavernous,  by  Onan- 
off,  is  another  of  the  recent  reflex  records  quite  similar  to 
and  associated  with  it. 

It  presides  over  the  virile  erection  and  when  1  first  made 
communication  on  the  subject  at  about  the  same  time  that 
Onanoff  did  in  France,  1  thought  it  was  the  same,  but  it 
is  not  precisely.  It  is  a  downward  jerk  of  the  organ,  not 
a  twitch  or  an  erection. 

The  following  are  the  other  principal  reflexes: 

The  patellar  tendon  or  quadriceps  extensor  femoris, 
vastus  intima  and  sub-crurens  muscle  reflex  caused  by 
briskly  and  suddenly  tapping  the  tendon  patella-  just  below 
the  knee  cap  while  the  legs  are  crossed  or  dangling  loose 
from  a  table.  This  is  the  typical  reflex.  The  others  are 
like  unto  it. 

Next  we  have  the  ankle  reflex  and  ankle  or  foot  clonus. 

The  wrist  reflex,  the  hamstring  muscle  and  tendon  re- 
flex behind  the  knee,  a  reflex  well  known  to  school  boys, 
elicited  by  striking  the  hamstring  tendons  while  the  man  is 
standing  upright. 

The  triceps  tendon  reflex  or  elbow  jerk.  The  biceps  re- 
flex.    The  shoulder  and  scapular  reflexes. 

The  jaw  jerk  or  chin  reflex. 

The  pupillary  and  ciliary  reflexes. 

The  pectoral  reflexes. 

The  plantar  reflexes. 

The  lesser  toe  extensor  reflexes. 

The  great  toe  extensor  reflexes. 


319 

The  reverse  extensor  response  of  the  great  toe  or  sign 
of  Babinski,  said  to  indicate  lateral  sclerosis  of  the  cord. 

The  cremasteric  and  scrotal  reflex. 

The  penile  and  virile  reflex. 

The  abdominal  and  epigastric  reflexes  or  rectus  abdom- 
inalis    reflexes. 

The  erector  spinal  reflex. 

The  scapular    reflex. 

The  palmar  reflex  (not  easily  elicited  in  the  waking 
state). 

The  conjunctival  or  eyelid  retinal  reflex  to  light  and 
mechanical  irritation. 

The  retino-papillary  reflexes. 

The  skin  pupil  reflex  from  irritating  skin  of  anterior 
lateral  side  of  neck,  cheek  or  chin. 

The  cilio-spinal  pupillary  reflex  from  irritating  cilio- 
spinal  center  of  cervical  cord. 

The  reaction  of  degeneration  reflex  ending  in  lost 
reflex. 

Then  there  are  tremors  of  muscle,  tongue  or  extremi- 
ties indicating  wasting,  exhaustion  and  degeneration  of  muscles 
and  chores  movements  and  tics,  all  dependentupon  disturbance 
of  the  reflex  function,  as  likewise  are  certain  spastic  states, 
important  to  consider  in  diagnosis. 

There  are  many  more  reflexes  yet  to  be  discovered. 
Look  for  them  gentlemen,  and  when  you  find  them,  study 
their  significance.  Make  a  record  of  your  findings  and  your 
names  will  become  famous  in  diagnostic  neurology. 

The  flexor  digital  and  thumb  reflexes  are  other  re- 
flexes to  which  I  call  your  attention,  though  they  are  not 
yet  in  the  literature. 


320 

ADDENDUM. 

BABINSKl'S  SIGN.— H.  Schneider  has  found  that,  while 
it  is  practically  true,  nevertheless  the  assumption  that  the 
presence  of  Babinski's  phenomenon  indicates  a  lesion  of 
the  pyramidal  tracts  is  open  to  certain  theoretical  objections. 
The  normal  response  to  stimulation  of  the  sole  of  the  foot 
consists  of  two  reflexes  having  different  origins.  One  of 
these,  plantar  flexion  on  slight  stimulation,  is  a  cortical 
reflex,  while  the  other,  dorsal  flexion  of  the  toes,  with  asso- 
ciated movement  of  the  leg,  is  evoked  by  strong  stimuli 
and  is  of  spinal  origin.  Babinski's  sign  is  present  when 
slight  irritation  is  sufficient  to  produce  dorsal  flexion  without 
the  occurrence  of  plantar  flexion,  and  is  always  due  to  gen- 
eral increase  in  reflex  excitability.  It  may  be  caused  in 
two  ways:  first,  through  a  break  in  the  pyramidal  tracts, 
whereby  the  cerebral  reflexes  are  cut  off  (which  is  the  true 
Babinski),  or,  secondly,  in  conditions  of  increased  spinal 
activity  {e.g.  strychnine  poisoning),  or  of  decreased  cere- 
bral excitability  (stupor),  when  the  dynamic  excess  of  the 
spinal  response  suppresses  the  cerebral  reflex  and  simulates 
the  true  condition. — Berliner  klinische  IVochenschrift  in 
Kansas  City  Med.  hid.  Lan. 


321 


FIG.   150. 


covrf' 


I,  Scheme  of  the  brain. — C,  C,  cortex  cerebri ;  C.s,  corpus  striatum,  N./,  nucleus  lenticularis ; 
T.o,  optic  thalamus ;  v,  corpora  quadrigemina  ;  P,  pedunculus  cerebri  ;  H,.  tegmentum ; 
and/,  crusta;  I,  I,  corona  radiata  of  the  corpus  striatum;  2,  2,  of  the  lenticular  nucleus; 
3,  3,  of  the  optic  thalamus;  4,  4,  of  the  corpora  quadrigemina;  5,  pyramidal  fibres  from 
the  cortex  cerebri  (Flechsig) ;  6,  6,  fibres  from  the  corpora  quadrigemina  to  the  tegmentum ; 
m,  further  course  of  these  fibres;  8,  8,  fibres  from  the  corpus  striatum  and  lenticular  nucleus 
to  the  crusta  of  the  pedunculus  cerebri;  M,  further  course  of  these;  S,  S,  course  of  the 
sensory  fibres ;  R,  transverse  section  of  the  spinal  cord  ;  <■.  W,  anterior,  and  h.  \V,  posterior 
roots;  it,  a,  association  system  of  fibres ;  c.  c,  commissural  fibres.  II,  Transverse  section 
ihrough  the  posterior  pair  of  the  corpora  quadrigemina  and  the  pedunculi  cerebri  of  man 
— ■/,  crusta  of  the  peduncle  ;  s,  substantia  nigra  ;  v,  corpora  quadrigemina,  with  a  section; 
of  the  aqueduct.     Ill,  The  sameofthe  dog;  IV,  of  an  ape;  V,  of  the  guinea-pig. 


322 


MOTOR  CELLS  OF  ANTERIOR  CORNUA  OF  CORD  OF  A  PUP. 
I  [G.   151. 


LENHOSSEK'S    CROSS    SECTION    OF    HUMAN    SPINAL    CORD, 

SHOWING   COLUMN   CELLS  AND   INTER-COMMUNICATIONS. 

FIG.    152. 


323 

The  reaction  of  degeneration,  which  we  have  already 
discussed  somewhat,  is  a  neuro- muscular  phenomenon  de- 
pendent upon  the  relation  of  the  central  and  sensory  motor 
nervous  system  to  the  muscles  involved,  and  the  muscles  are 
usually  involved  in  atrophic  degeneration,  too,  as  well  as 
the  connecting  nervous  system.  Progressive  myatrophy  or 
muscular  atrophy  is  the  nervous  system  disease,  in  which 
this  phenomenon  is  most  typically  displayed.  It  is,  in  fact, 
a  progressive  neuro-myatrophy.  Rapid  degeneration  and 
slow  reaction  to  electricity  characterize  Wallerian  degener- 
ation and  its  reaction  to  degeneration. 

Degeneration  of  the  pyramidal  tracts  follows  degenera- 
tive nerve  change  at  the  top  or  the  pyramids,  as  in  the  en- 
eapsular  or  destructive  inter-ventricular  extravasation  or 
syphilitic  or  atheromatous  cerebral  artery  degeneration 
and  destruction  of  brain.  According  to  Russell,  if  the  vermis 
of  the  cerebellum  is  removed,  the  vestiform  bodies  degen- 
erate. Von  Gudden  removed  the  eye  of  rabbits  at  birth, 
and  afterwards  found  their  optic  chiasma  and  optic  tracts 
degenerated.  Nissl  showed  alterations  in  neurones  after  cut- 
ting off  their  neuraxones. 

As  we  have  already  seen  muscles  and  nerves  in  cer- 
tain diseases  of  the  nervous  system  respond  differently  from 
the  normal  reaction  to  electrical  impression.  Their  impres- 
sion excitability  to  this  stimulation  is  changed  both  in  quan- 
tity and  quality.  The  muscular  contractions  vary  in  in- 
tensity, in  promptness  and  in  character,  and  after  a  time 
they  cease  to  respond  at  all.  Irritability,  responsive  to 
electrical  stimulation  varies  here  remarkably,  as  the  reflex 
responses  in  various  parts  of  the  body  differ  to  percussional 
impression,  being  unduly  rapid  jerks,  slow  or  irregular. 
Usually  when  the  reflexes  respond  in  exaggerated  manner 
to  the  sharp  stroke  of  the  pleximeter  or   hand,  the  muscles 


324 

respond  or  fail  to  respond  likewise  to  electrical  excitation, 
as  they  do  in  chorea,  tetanus,  antero- lateral  sclerosis,  pos- 
terior sclerosis,  transverse  myelitic  paralysis,  progressive 
muscular  atrophy,  etc. 

It  has  also  long  been  known  that  nerve  center  changes 
take  place  after  amputation,  disuse  or  injury  to  peripheral 
nerves,  etc.  Toxa-mia.  anaemia,  peripheral  irritation,  shock, 
etc.,  may  derange  and  disease  central  neurones  of  cord  or 
brain  and  even  of  ganglionic  centers. 

Spinal  cord  changes  follow  operations.  Switalski  re- 
ports the  results  of  an  examination  of  five  spinal  cords  re- 
moved from  subjects  upon  whom  amputations  had  been  per- 
formed— four  amputations  of  the  thigh  and  one  of  the  leg. 
In  every  case  there  was  found  atrophy  of  one-half  of  the 
spinal  cord  corresponding  to  the  side  of  the  operation,  both 
the  white  and  grey  matter  being  implicated  in  the  atrophy. 
In  three  cases  the  atrophy  was  traceable  from  the  lumbar 
part  of  the  cord  to  the  dorsal  region  and  in  two 
cases  up  to  the  cervical  region.  Coincident  with  the 
atrophy  there  occurred  a  sclerosis  of  the  posterior  columns — 
in  three  cases  in  all  levels  of  the  cord,  in  two  cases  in  the 
cervical  region.  While  the  spinal  hemiatrophy  showed  a 
tendency  to  diminish  from  below  upward,  the  sclerosis  of 
the  posterior  columns  increased  from  below  upward.  Pierre 
Marie  also  draws  attention  to  the  occurrence,  not  only  of 
atrophy,  but  also  of  sclerosis  after  amputation,  and  states 
that  such  sclerosis  may  be  noticeable,  even  on  the  opposite 
side  of  the  cord. — Switalski,  {Rev.  Neurol.  Jan.  15,  1901), 
Gould's  American  Year  Book. 

These  changes  illustrate  Von  Gudden's  law  of  peri- 
phero-central  change,  while  Waller's  law  is  one  of  centro- 
peripheral  change. 

The  accompanying  illustrations  from  Marinesco  and 
Raymond  show  the  neurone  changes  resulting  from  section 
of  a  peripheral  nerve. 


325 


FIG.  153. 


FIG.   154. 


Ecorcc-  rcrebraZo 


fibre.  pyramuLale. 


N.c  neurone  central.  —  iV.p., 
neurone  periphoriquc.  =C.p.s., 
cellule  pyramidale.  —  C.m.- 
cellule  motrice  des  comes  an- 
terieures  de  la  moelle. 


1   (Testut  :  Anatomie). 

1,  segment  anterieur  de  la  capsule  interne.  — 
2,  son  segment  posterieur.  —  3,  son  genou.  — 
4,  noyau  lenticulaire.  —  5,  noyau  ca"  '  \  — 
6,  couchc  optique. 

{After  Raymond.) 


Fig.  153.  Origin,  course  and  termination  of  a  motor  impulse.  A 
pyramidal  fiber,  coming  from  a  neurone.  C.  p.  s.,  in  the  cerebral  cortex  or 
central  neurone,  with  it  neuraxone,  N.  c,  to  the  anterior  cornua  of  the 
spinal  cord  and  pyramidal  cell  C.  m,  A  motor  cell  prolongation  neuraxone 
or  motor  nerve  goes  out  at  N.  p.  to  the  muscle. 


Fig.  154.  1,  anterior  segment  of  internal  capsule;  2,  posterior  seg- 
ment of  the  internal  capsule;  3,  genu  of  the  internal  capsule;  4,  lenticular 
nucleus;  5-5,  caudate  nucleus;  6,  optic  thalamus  or  optic  bed;  12,  claus- 
tram;    13,  external  capsule. 


326 


CEREBRAL  TRANSVERSE  SECTION. 
FIG.   155. 


a,  a  ,  b,  group  of  pyramidal  cortex  neurones;  a,  a,  cortex  neurone 
sending  its  axone  or  neuraxone  directly  down  c,  the  pyramidal  tract  into  the 
cord,  a  cerebro-spinal  fasculus  or  true  axone  of  the  pyramidal  tract;  a,  an- 
other pyramidal  cortex  neurone  sending  its  neuraxone  the  same  way  and 
also  a  bifurcation  of  its  neuraxone  across  the  corpus  callosum  to  the  oppo- 
site hemisphere  of  the  brain;  b,  cortex  neurone  sending  its  neuraxone 
through  the  corpus  callosum;  c,  pyramidal  neurone  with  bifurcating  neu- 
raxone, one  arm  going  across  to  the  corpus  callosum  opposite,  the  other  to 
cortex  of  the  same  side;    d,  collateral;    e,  terminal  callosal  fibers. 

[Further  illustrations  of  this  chapter  may  be  found  in  Figs.  151,  152, 
et  seq.] 


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CHAPTER  XXV111. 


THE  CEREBRO-SPINAL  AXIS  OR  NEURAXIS  AND  ITS  NERVE  CENTERS. 


G  W  ILIA,  PLEXUSES,  NEURONES  AND  NERVE  CENTERS.      IMPORTANCE  OF 

THE  PUPIL  AND  OTHER  NERVE  CENTERS  IN   DIAGNOSIS— THE 

BASAL  AND  OTHER  GANGLIA— THE  NEURAXIS 

AND  THE   NEURAXONE. 

The  cerebro-spinal  axis,  also  called  the  encephalo-spinal 
axis  and  designated  also  as  the  neuraxis,  must  not  be  con- 
founded with  the  neuraxone  of  a  neurone,  which  has  already 
been  briefly  considered.  These  terms  might  be  confounded 
nominally,  but  the  respective  regions  of  the  neuro-anatomy 
designated  by  them  could  not  be  confounded  from  observa- 
tion. The  neurone,  though  it  has  itself  a  nucleus  and  nu- 
cleolus as  we  have  already  seen,  is  an  integer  of  the  neu- 
raxis or  cerebro-spinal  axis.  I  prefer  the  latter  term,  as 
most  of  your  text- books  do,  for  the  present,  because  it  is 
less  confounding.  The  neurones  are  the  nuclear  nuts,  so  to 
speak,  of  the  cerebro-spinal  axis,  out  of  which  the  neuraxis 
is  developed.  They  are  nuts  for  you  to  crack.  In  them  is 
the  meat  of  the  nerve    centers. 

The  neurone  is  a  microscopically  discernable  organized 
element  of  structure.  The  cerebro-spinal  axis  (neuraxis)  is 
an  aggregation  of  organs  and  centers  of  action,  sensation, 
perception,  reflection,  motion,  etc.,  made  up  of  groups  of  neu- 
rones and  their  receiving  and  projecting  fibers,  and  located 

[328] 


329 

within  the  bony  cavities  of  the  head,  neck  and  back.  Nerve- 
centers  are  made  up  of  aggregated  neurones,  which,  as  we 
have  seen,  are  nerve  cells  with  all  of  their  micro-anatomi- 
cal attachments.  The  relation  of  the  nut  to  the  developed 
tree  and  the  tree  to  the  forest  will  give  you  a  conception, 
though  not  a  perfect  one,  of  the  neuroses  and  their  nuclei 
and  nucleoli  to  nerve  centers  and  organs.  The  neurones, 
however,  are  completely  developed  microscopic  individual- 
ities and  make  up  by  anatomical  and  physiological  group- 
ing, the  several  centers  or  neurone  aggregations  of  the 
spinal  cord  and  cerebrum  and  making  with  their  sensory 
and  motor  attachments  the  incoming  and  outgoing  nerve 
connections,  the  cerebellum,  pons  Varolii  and  the 
spinal  cord.  The  upper  portion  of  the  cerebro-spinal 
or  encephalo-spinal  axis  is  made  up  of  all  the  nervous  mat- 
ter within  the  cranium  above  and  down  to  the  foramen 
ovale,  called  the  encephalon,  including  the  great  brain  or 
cerebrum  and  lesser  brain  or  cerebellum  and  the  interme- 
diate connecting  or  mid  or  tween  brain,  made  up  of  the  pons 
Varolii,  the  medulla  oblongata,  the  crura-cerebri,  are  here  lo- 
cated. The  lower  portion  of  the  cerebro-spinal  axis  is  all 
of  the  spinal  cord  and  attachments  located  within  the  spinal 
canal  and  sacral  cavity  down  to  the  coccyx.  The  cauda 
aquina  is  the  lowest  attachment  of  the  cerebro-spinal  axis. 
The  cerebrum  and  cranial  nerves  make  up  the  uppermost 
part  and  belong  to  this  great  nerve  axis,  while  the  peri- 
pheral nerves  (motor  and  sensory)  including  those  of  the 
sympathetic  system,  constitute  the  intervening  connections 
of  this  great  nerve  center  line  of  nerve  impression  and  ac- 
tion within  the  body. 

The  cerebro-spinal  axis  or  neuraxone  is,  as  you  see,  an 
aggregation  of  important  centers  of  nervous  impression  and 
expression;  centers  of    nerve  energy  or  ganglionic    centers, 


330 

as  they  are  often  called   in  your    treatises  on  neuro- physi- 
ology.    But  there  are  other   centers    of    nervous  energy  or 
force.     These  are  aggregations  or   enlargements  or  knots  of 
substance,  from  yayyAiov,  a  swelling. 

There  are  ganglions  in  automatic  and  surgical  nomen- 
clature or  swellings  of  the  muscular  tendons.  The  latter 
are  serous  tendinous  tumors  sometimes  called  "weeping 
sinuses"  and  often  found  on  an  extensor  and  sometimes  on 
a  flexor  tendon  of  the  wrist,  etc.  But  the  ganglions  we  are 
now  dealing  with  is  a  neural  ganglion  or  hunched  aggrega- 
tion of  neurones  or  nt-rves.  The  ganglia  of  the  peripheral 
nervous  system  are  those  of  the  sympathetic  nervous  sys- 
tem and  those  on  the  roots  of  the  posterior  spinal  nerve 
roots,  which  you  will  see  in  the  accompanying  illustrations 
of  the  cerebro-spinal  axis,  and  the  ganglia  of  the  roots  or 
trunk  of  the  cranial  nerves,  the  most  important  of  which 
from  the  standpoint  of  neuriatry  or  the  treatment  of  ner- 
vous disease,  is  the  great  Gasserian  ganglion  or  the  great 
center  of  the  three  roots  of  the  fifth  or  tri-facial  nerve,  with 
which  we  become  familiar  in  practice,  in  connection  with  the 
treatment  of  tri-facial  or  trigeminal  neuralgia  or  prosopalgia 
or  tic  doloureux,  as  it  is  called. 

The  geniculate  ganglion  of  the  facial  or  seventh  nerve, 
is  a  peripheral  ganglion  which  will  not  interest  you  as  much 
as  the  Gasserian  ganglion,  of  the  fifth  or  tri-facial  nerve,  for 
the  Gasserian  ganglion  is  the  one  the  surgeons  will  want  to 
take  out  of  your  tri-facial  neuralgics,  some  of  them,  before  you 
have  a  fair  chance  at  curing  them.  Our  surgical  friends  in  the 
faculty,  Profs.  French  and  Keifer,  wield  the  knife  so  deftly  that 
they  like  to  use  it  in  these  cases  and  sometimes  surgery  is 
the  only  source  of  relief.  Some  of  my  cases  in  my  life  time 
of  practice  have  been  passed  over  to  the  surgeon  and  been 
finally  relieved    after    many  years  of  recurring    suffering  by 


331 

this  formidable,  but  in  extreme  cases,  when  the  nerve  be- 
comes degenerate,  very  necessary  operation.  They  were 
successfully  operated  on  by  a  surgeon  specially  skilled  in 
Gasserian  gangliectomy.*  Drs.  Bartlett,  French,  MacCand- 
less,  Lutz  and  others  have  also  succeeded  in  this  operation. 

The  glossopharyngeal,  vagus  and  auditory  nerves  have 
ganglia  and  the  visual  expansion  of  the  optic  nerve  has  like- 
wise. It  is  called  the  retina,  and  includes  all  of  its  nerve 
elements  concerned  in  the  reception,  elaboration  and  trans- 
mission inwards  of  sight  impression.  It  has  been  called  the 
retinal  ganglion  or  ganglion  of  the  retina.  This  ganglion  will 
interest  you  much  in  practice,  as  well  as  the  pupil  and 
movements  of  the  iris  and  action  of  the  retina,  that  make 
up  its  many  interesting  movements  in  disease,  as  well  as 
in  mental  emotion. 

The  ganglia  of  the  sympathetic  system  comprise  the 
ophthalmic  (lenticular  or  ciliary)  in  the  orbit,  the  spheno- 
palatine, Meckel's  or  nasal  ganglia,  in  the  spheno-maxillary 
fossa  and  at  the  other  extreme  the  ganglia  of  impar  on  the 
anterior  aspect  of  the  coccyx.  Arnold's  ganglion,  the  otic, 
lies  beneath  the  base  of  the  skull,  the  sub-maxillary  or  lin- 
gual, located  as  its  name  implies,  likewise  the  superior  mid- 
dle and  inferior  and  inferior  cervical  or  neck  ganglia,  the 
middle  of  which  is  called  the  thyroid,  from  its  relations  to 
that  gland.  Then  there  are  the  thoracic  ganglia  along  the 
thoracic  spine,  the  semi-lunar  ganglia  and  solar  plexus  back 
of  and  abtve  the  umbilicus  and  below  the  diaphragm,  the 
sub-diaphragmatic  ganglion  under  the  surface  of  the  dia- 
phragm, the  ganglia  of  the  lumbar  and  sacral  regions ;  the  mes- 
enteric and  renal  ganglia  supplying  the  kidneys,  mesentery 
and  renal  and  mesenteric  arteries.  Then  there  is  the  gan- 
glion of  the  coccyx,  (impar),  which,  unlike  the  other  spinal 

*  Dr.  Carson. 


332 

sympathetic  ganglia,  we  have  mentioned  as  lying  on    each 
side  of  the  vertebral  column  is  placed,  as  its  name  implies, 
solitary  and    alone  on  the  front  of   the  coccyx.     You     may 
retain    approximate    remembrance  of    the    location   of   those 
ganglia    of    the    sympathetic    system  by    recalling   the    fact 
that  the    ganglions  of  Meckel    and    Arnold    (the    nasal    and 
otic)   are  in  pairs  at    the   upper  extreme  of  this    region  and 
itnpar  (not  paired)   as  its  name  implies,  is  solitary  and  alone 
at  the  other    and  lower  extremity  of    the    trunk,  while  the 
other  ganglia    intervene  and  derive    their  respective    names 
from  their    anatomical    location    and  relations   to    viscera  or 
regions    of    the  body,  except    the    ganglia   of    the    cochlear 
branch  of  the  auditory  nerve,  which  unfortunately  for  your 
remembrance,  is  not  called  the  auditory  or  aural  or  cochlear, 
as  I  would    have  named  it  for  your  sakes,  had    1  been    the 
discovering  anatomist,  keeping  in  view  all  the  hard    names 
you  have  to  learn,  but  the  spiral  ganglion  or  ganglione  spirale. 
Fortunately    you  will    not  have  to  keep    constantly     in 
mind    all  the    names  or  all  the  ganglia    of  the    sympathetic 
system  in  order  to  make  good  practitioners.     You  will  only 
have  to  locate  them   from    time  to  time,  as  you    may    have 
to  describe    particular  parts  on    study    particular    viscera  in 
disease.     The  main  thing  for  you  not  to  forget  is  that  these 
ganglia  are  connected  with  involuntary  visceral  and  vascular 
functions,  that  they    are  in  the  main  centers  for   control  of 
the  unconscious    life-maintaining  movements  of   the    organs 
and  circulation  vessels.      They  and  their    neural    prolonga- 
tions or    nerve    fiber  connections    have    to    do  with    uncon- 
scious   motion,  sensation    and    inhibition.     They    keep    the 
involuntary    machinery     of     our    wondrous    mechanism     in 
normal    movement.     When    disease    damaged,  they    permit 
the  marvelous  machinery  of  man  to  go  wrong  or   aid  in  its 
morbid  movement. 


333 

The  possession  of  involuntary  sensation  will  be  denied 
to  the  sympathetic  system,  but  do  not  believe  the  conten- 
tion. There  is  probably  more  in  the  philosophy  of  the 
mechanism  of  the  sympathetic  system  movements  than  has 
yet  been  described  in  your  physiologies.  Unconscious  sen- 
sation in  the  sympathetic  system  is  as  rational  as  reflex 
movement  and  inhibition  without  sensation.  It  is  here 
largely  through  the  sympathetic  system  and  its  mechanisms 
of  impression  and  control  movement,  that  we  live  and 
move  and  have  our  being  in  our  unconscious  life,  especially 
below  the  encephalon.  There  is  an  organic  consciousness, 
if  1  may  so  express  it,  of  which  we  may  conceive,  though 
we  may  not  prove  it;  an  organic  consciousness  to  be  dis- 
tinguished from  psychic  consciousness  or  the  self-conscious 
consciousness,  if  I  may  so  recall  it,  which  appears  to  reside 
in  the  psychic  neurones  of  the  conscious  mind  areas  of  the 
grey  matter  of  the  brain.  The  semilunar  and  solar  plexus 
ganglia  have  been  termed  the  ventral  brain. 

CENTRAL   NERVOUS    SYSTEM  GANGLIA. 

Notwithstanding  the  number  and  importance  of  the 
ganglia  already  mentioned,  they  have  been  called  the  lower 
or  lesser  ganglia  of  the  nervous  system.  There  are 
ganglia  of  far  more  primary  importance  called  the  great 
ganglia  of  the  central  nervous  system  or  cerebro-spinal  axis. 
The  principle  of  these  are  called  the  basal  ganglia  and 
the  chief  or  these  are  the  corpus  striatum  and  the  op- 
tic thalamus.  These  two  are  generally  referred  to  as  the 
basal  brain  ganglia,  as  if  there  were  no  others.  The  corpus 
striatum  is  located  anteriorly  a  little  superiorly  and  ex- 
ternally and  the  optic  thalmus  is  placed  posteriorly  and  in- 
teriorly and  slightly  internally,  nearer  the  median  line  in 
relation  each  to  the  other.     The   hemispheres   of    the  cere- 


334 

brum  are  called  the  hemispheral  ganglion,  making  the  striate 
bodies  and  the  optic  beds  intermediate  ganglia.  Below 
these  are  the  geniculate  bodies,  tuber  cinereum,  olivary  bod- 
ies, etc.  The  two  ganglia,  which  all  authors  agree  in  call- 
ing the  basal  ganglia,  that  is  the  thalami  optici  and  the  cor- 
pora striata,  1  show  you  here  in  the  lateral  ventricles,  bor- 
dering the  fifth  ventricle  of  the  system,  the  most  anterior  and 
superior.  The  third  ventricle,  you  see,  is  situated  poster- 
iorally  and  the  fourth  ventricle  is  out  of  sight,  but  posterior 
and  below  the  third  with  this  canal  with  the  long  Latin 
name,  in  which  1  have  placed  the  probe  leading  to  it,  the 
iter  a  tertio  ad  quartum  ventriculum,  or  acqueduct  of  Sylvius. 
Note  their  situation  with  reference  to  these  two  important 
ventricles,  the  two  largest  ventricles  of  the  brain,  as  these 
two  ganglia  are  also  the  largest  and  most  important  of  the 
ganglia  of  the  cerebrum  except  the  two  hemispheres  of  the 
cerebrum,  which  are  themselves  called  ganglia,  hemispheri- 
cal ganglia. 

These  two  ventricles  are  on  either  side  of  the  median 
line  with  their  longest  diameters  antero- posterior,  while  two 
of  the  other  ventricles  are  in  sight  between  them,  the 
one,  the  fifth,  within  the  pellucid  septum  which  divides 
the  lateral  ventricles  from  each  other,  and  the  other,  the 
third,  on  a  straight  line  backward  and  emptying  into  the 
front  end  of  the  Sylvian  acqueduct. 

The  encephalo-spinal  axis  is  originally  described  as  con- 
sisting of  the  frontal,  temporal  and  occipital  lobes  of  the  two 
hemispheres  of  the  brain,  the  joined  hemispheres  and  lobes 
of  the  cerebellum  or  little  brain  (the  cervellet,  as  the  French 
call  it),  the  bridge  of  Varolius  or  pons  Varolii  or  pons  as  it  is 
variously  called,  the  oblong  marrow  or  medulla  oblongata  or 
simply  medulla,  as  it  is  generally  designated,  and  the  cord 
or  spinal  cord. 


335 

The  accompanying  illustrations  (  Figs.  153  to  161  in- 
clusive) will  explain  the  subject  more  clearly.  The  spinal 
cord  is  brought  into  proper  relation  with  its  environment 
within  the  system  by  means  of  the  sensory  and  chiefly  the 
sympathetic  systems;  the  latter  may  properly  be  regarded  as 
a  system  of  subsidiary  spinal  nerves  of  communication  with 
blood  vessels  and  viscera.  By  means  of  the  spinal  nerves 
proper  and  the  nerves  of  special  sense  of  the  brain  this 
great  nervous  axis  is  brought  into  contact,  for  sensa- 
tion and  motion,  with  the  environment  of  the  outside 
world  and  the  environing  body.  It  is  the  greatest  aggrega- 
tion of  nerve  centers  of  the  body.  But  as  most  of  the 
ganglia  of  the  nervous  system,  encephalic,  spinal  and  peri- 
pheral, including  also  the  sympathetic  system,  have  been 
demonstrated  to  be  centers  of  nervous  energy,  that  is,  to 
possess  power  of  transmuting  sensation  into  various 
kinds  of  motion  and  to  modify,  transmit  and  arrest  sensa- 
tion, the  central  nervous  system  can  not  be  properly  con- 
fined exclusively  to  the  cerebro- spinal  axis.  Since  this  is 
the  fact,  the  term  neuraxis  might  well  be  restricted  to  the 
brain  and  spinal  cord,  taking  care,  as  1  have  already  en- 
joined, not  to  confound  the  term  with  the  still  more  re- 
strictive and  microscopic  term  neuraxone,  the  efferent  pro- 
longation of  the  neurone,  as  we  have  seen.  The  neuraxis 
is  nevertheless  the  greatest  part  of  the  nervous  system,  the 
head  and  backbone  nerve  center  arrangement  of  the  entire 
neural  framework  of  the  human  body.  The  many  anatom- 
ical illustrations  now  shown,  with  the  brief  descriptions  that 
follow,  will  illustrate  more  forcibly  than  words  alone,  how 
important  this  great  cerebro- spinal  system  really  is.  The 
neuraxis,  like  Banquo's  ghost,  continually  comes  up  before 
us  in  the  study  of  neurology  with  its  psycho-neural  daugh- 
ters, psychology    and    alienism,  and    will  not    down  at    our 


336 


ILLUSTRATION  OF  A  PORTION  OF  UNDER  SURFACE  OF  BRAIN  IN  IMMEDI- 
ATE CONNECTION  WITH,  AND  CONTINUATION  UPWARD  FROM,  THE 
SPINAL  CORD.  ALL  THE  CRANIAL  NERVES  ARE  HERE  SHOWN,  AND 
MARLY  ALL  THE  UPPER  (CRANIAL)  PART  OF  THE  CEREBRO-SPINAL 
AXIS.  THE  OPTIC  NERVE  DISTRIBUTORS  DO  NOT  SHOW,  NOR  DOES 
ANY  OF  THE  LEFT  HALF  OF  THE  BRAIN  APPEAR  EXCEPT  THE  OPTIC 
THALAMUS,  THE  LEFT  CRURA  CEREBRI,  OPTIC  TRACT,  ETC.,  DE- 
SCRIBED UNDER  THE  CUT.  THE  ANTERIOR  UNDER  LOBE  ON  RIGHT 
APPEARS  AS  LIFTED  AND  PRESSED  UP  AND  FATTENED  SOME. 

FIG.   157. 


Superficial  Origins 
I'.  "Olfactory  tract. 


HI.  1 


Mil 
hi,d 


otulo-motor 


IV.  Fourth  nerve. 

V.  Fifth  nerve,  sensory  root. 
V  -f  Fifth  nerve,  motor  root. 
M.j   Maindivis.onsoffiflh 

VI.  Si*»h  nerve.      " 

VII.  Facial  nesve. 

VIII.  Auditory  nerve. 

IX.  Closso* pharyngeal 

X.  Vagus. 

XL    Spinal  accessory 


OP  Cranial  Nervks  {Jrom 

XII.  Hypoglo    - 

CI.  First  cervical  nerve. 

C.   Island  of  Keil. 

Th  Optic  thalamus  ItlTe  Is. 
land  of  Rcil  having  been 
removed).  [mm 

i.  Internal  corpus  gemcula- 

t    External  gcniciilatum 

A.  Pituitary  body. 

Ic    Tuber  cinereum 

a,  Ooe  of  the  corpora  albi. 

£y    Sylvian  fissure. 
xx    Anterior    perforated 
space 


Qucim  s  "  AnMcfiy"). 

x    Posterior   perforated 

space. 
P.  C«rcbral  pcdiioclc. 
PV     Pons  Varolii. 
Cc    Cerebellum. 
/    Fillet 
JI.  F'loccuITrs. 

/<j     Anterior  pyramid 


lisiuri 


Ollv 
J    Anlerir 
of  cord." 
K  Lateral  oract  of  medulla. 
£x.  Anterior  column. 
CI.  Lx*uj\  column. 


337 


IMPORTANT   NERVE  CENTERS   OF  THE  CORD  AND   MEDULLA. 
FIG.    158. 


Ilypo-glossnl  X. 

LTncuuioga?tric  X. 

Plwrcnjc  N. 


W  vyvs^Cy  o^  -fcSUa/  c<rv£/  CXJUo 


338 

bidding,  though  some  of  you  might  wish  to  ignore  it. 
It  is  essential  to  understand  the  brain  nerves  of  special 
sense  and  their  related  nerves,  in  origin  and  function, 
in  order  to  become  proficient  in  the  diagnosis  oi  brain  and 
even  some  forms  of  spinal  cord  disease,  especially  diseases 
involving  th  :al  or  neck  region,  the  area  of  the  cilio- 

spinal  or  pupil  dilating  center,  in  the  lower  part  of  the 
cervical  cord,  belonging  to  the  brain  region  of  the  neuraxis 
or  cerebro-spinal  axis.  So  also  are  classified  as  cerebral 
nerves  the  remainder  of  the  dozen  cranial  nerves, 
and  they  are  of  .meat  importance  in  determining  the  nature 
and  extent  of  lesions  or  disease.-  The  pupil  is  influenced 
in  its  contracting  striae  by  fibers  from  the  sphincter  pupil  - 
lae  or  third  nerve  and  dilation  by  a  sympathetic  nerve  cen- 
ter from  the  cord,  sending  its  fibers  of  nerve  influence  with- 
in the  cranial  cavity  to  the  pupil.  They  are  symptom- 
atic signboards  and  roads  that  lead  and  point  to  intracer- 
ebral centers.  They  tell  us  where  to  find  and  often  the 
exact  nature  of  the  brain  or  upper  spino-cerebral  disease, 
we  may  be  seeking  to  discover  and  understand. 

The-  nmst  important  nerve  extending  below  the  face  and 
originating  from  the  upper  (cerebral)  portion  of  the  cerebro- 
spinal axis  is  the  vagus  or  pneumo-gastric.  It  arises  from 
the  floor  of  the  fourth  ventricle  and  is  distributed  to  the 
viscera  of  the  thorax  and  abdomen.  It  might  well  have 
been  named  from  its  anatomical  relation  with  the  viscera 
and  its  origin,  the  cerebro-pneumo-cardio-hepatico-enteric 
nerve,  so  numerous  and  important  are  its  relations,  inser- 
tions and  functions,  with  the  thoracic  and  abdominal  viscera. 
The  next  most  important  nerve  center  of  the  spinal 
cord,  though  none  of  them  are  unimportant  to  health  and 
life,  is  the  pudic  nerve  center  in  the  lower  part  of  the 
cord.       It  is    the    center    on    whose    integrity    depends    the 


339 

power  of  procreation  and  normal  action  of  the  genesiac 
function.  1  need  not  enjoin  you  to  take  good  care  of  it  and 
to  neither  overwork  it  nor  to  let  it  wrongly  govern  your 
life.  The  student  who  lives  too  much  below  the  belt  does 
not  usually  live  best,  nor  does  he  do  the  most  good  above 
the  collar.  Some  important  diseases,  mental  and  physical,  are 
connected  with  genesiac  center  disorders.  The  vagus  center 
and  the  centers  there  about  it,  in  the  upper  cerebro-spinal 
axis,  contribute  to  maintain  or  shorten  life.  The  pudic  nerve 
center,  in  association  with  the  ovarian  plexus,  branching 
off  from  the  renal  and  aortic  plexuses,  is  closely  related 
to  the  vesical  and  rectal  centers  in  the  lumbo-sacral 
region  of  the  lower  neuraxis,  and  aids  in  the  propogation 
of  life.  The  genital,  rectal  and  bladder  functions  are 
extensively  innervated  and  maintained  from  this  region  of 
the  encephalo-spinal  axis.  The  seminal  and  ovarian  man- 
ufacturies  have  their  life  making  and  life  continuing  plant 
located  near  by  in  the  pelvis  and  further  up  in  the  cord 
and  the  two  great  reservoirs  and  secretory  sewers  of  the 
body  have  their  cess-pools  and  waste  product  exits  in  the 
vicinity  here,  and  they  are  presided  over  and  regulated  in 
the  very  important  functions  of  holding  in  or  expelling  their 
contents,  by  this  part  of  the  cord. 

The  term  center  comes  from  the  Greek  kIvtttov,  signi- 
fying a  point  around  which  a  circle  may  be  drawn.  And, 
as  in  geometry  and  mechanics,  we  have  centers  of  curva- 
ture and  gyration,  in  hydrostatics  and  mechanics,  centers  of 
pressure,  and  in  physics  centers  of  cohesion  and  attraction, 
and  in  astronomy  centers  of  gravity  and  motion,  so  in  neu- 
rology we  have  centers  of  impression  (direct  and  reflected 
impression  action)  and  expression  and  repression,  and  these 
centers  are  designated  nerve  centers,  the  nerve  centers  of 
the  encephalo-spinal  system,  including  the  sympathetic  and 


34n 


Fig.  159  (opposite  page)  is  the  spinal  incasement  of  the  cerebro-spinal 
axis  showing,  after  an  illustration  of  Gowers,  the  relation  of  the  vertebral 
spines  to  their  bodies  and  the  nerve  roots.  The  ends  of  the  vertebral 
spines  are  opposite  the  middle  of  their  own  bodies  in  the  lumbar  region  only. 
They  correspond  to  the  lower  edge  of  their  own  bodies  in  the  cervical  and 
last  two  dorsal,  and  to  the  upper  part  of  the  vertebral  bodies  in  the  remain- 
ing dorsal  region. 

A  careful  study  of  the  illustration  will  help  you  to  understand  the 
mutual  relation  of  the  cord  segments  and  nerve  exits  as  well  as  the  spine 
and  body  vertebral  relations.  Note  that  generally  the  spinal  nerves  emerge 
from  the  vertebral  interspaces  at  a  segment  below  their  points  of  origin, 

The  sixth  dorsal  nerve  has  Its  origin  opposite  the  fourth  dorsal 
vertebra,  the  fifth  lumbar  nerve  between  the  eleventh  and  twelfth  dorsal  and 
the  sixth  dorsal  nerve  between  the  third  and  fourth  dorsal  spines. 


ILLUSTRATIONS  OF  PARTS  OF  THE   NEURAXIS    OR  CEREBROSPINAL  AXIS 
AND   CONNECTIONS,  CHIEFLY  BELOW  THE   ENCEPHALON. 


Fig.  161.     Encepr.alo-spinal    and     gan- 
gliated  nerves.    (Ferrier,  after  Quain.) 


Fig. 159.  Relations  of  the  spinal  nerve  to  the 

bodies  and  spinous  processes  of  the  vertebrae. 

The   positions  of   the   letters    and  numbers, 

clearly  indicate  the  parts.     (After  Gowers.) 

Fig.  160.  1,  antero- inferior  wall  of  the  fourth  ventricle:  2,  superior  peduncle  of  the  cerebel- 
lum; 3,  middle  peduncle  of  the  cerebellum:  4,  inferior  peduncle  of  the  cerebellum;  5, 
inferior  portion  of  the  posterior  median  columns  of  the  cord:  6,  glosso-pharyngeal 
nerve;  7,  pneumogastric;  S,  spinal  accessory  nerve;  9,  9,  9,  9,  dentated  ligament: 
10,  10,  10,  10, posterior  roots  of  the  spinal  nerves;  11,  11,  11,  11,  posterior  lateral 
groove;  12,  12.  12,  11,  ganglia  of  the  posterior  roots  of  the  nerves;  13,  13,  anterior 
roots  of  the  nerves;  14,  division  of  the  nerves  into  two  branches;  15,  lower  extremity 
of  the  cord:  16. 16,  coccygeal  ligament;  17,  17,  cauda  equina;  I — VIII,  cervical  nerves; 
I,  II,  111,  IV — XII,  dorsal  nerves;  I,  II — V,  lumbar  nerves;  1 — V,  sacral  nerves. — Hirsch- 
feld.     (For  further  description  see  next  page.) 


342 

the  vasomotor  or  the  vaso-motor  and  the  vaso-constrictor 
systems  of  the  nervous  system  concerned  in  contracting  or 
dilating  the  blood  vessels  —  the  vaso-motor  system.  And 
these  are  all    subject  to   disease  or   disease    impression  and 

you  must  therefore  know  something  about  them. 

Plexus  is  the  Latin  for  a  braid,  a  plait  or  an  inter- 
lacing.  There  are  various  interlacings  and  there  are  nerve 
interlacings  or  plexuses  as  well  as  nerve  ganglia.  They 
should  not  he  confounded  with  nerve  ganglions.  The 
former  is  An  aggregation  of  neurones,  the  latter  a  mingling 
of  nerves.  The  spermatic  or  pampiniform  plexus  is  a 
venous  plexus  with  nervous  innervation  from  a  ganglionic 
center,  by  which  nervous  innervation  every  properly  regu- 
lated man  is  expected  to  maintain  due  control  of  his 
pampiniform  plexus,  though  its  control  is  not  one  of  direct 
voluntary  control,  but  indirectlj',  through  restraining  the 
emotions,  well  ordering  the  thoughts  and  properly  manag- 
ing peripheral  influences.  Do  not  pander  to  your  pudic 
nerve  or  pampinform  plexus,  or  to  the  organs  they  are  in 
relation  with,  young  gentlemen. 

[Further  illustrations  of  this  chapter  may  be  found  in 
Figs.   151,   152  et  seq .] 


FIG.   162. 


343 


Olfactory  bulb 


Vertebral  artery 


Anterior  spinal 


G/vOei 


Anterior  cerebral  a. 


Lamina  tynerea. 
Middle  Cerebral  a. 
Tuber  cinereum. 
Mammillary  body. 
Locus  perforatus 

medius. 
Posterior  cerehn.l  a. 

Superior  cerebellar  L. 

Pons  Varolii. 

Inferior  cerebellar  a. 
Seventh  \  pair  of 
Eighth    \  nerves. 

?»£    lj£- 

Eleventh  J  ncrves- 

Twelfth  pair  of 

nerves. 
Cerebellum. 


i/Tpd-posXaVWc  Tooed v<vciu o-viA  \rAaiecX   W/>cwow    su*- 

VOvTeovVv    o^W\ei"o^©-Oj,  i«vvW^ft«v5  too SX^'v^c  ViVi^t 
o"£;,uc\A2,    c^TceVcvvwcv  o*x*&*  ^ve,  \wo  \.©\acs  ©"^  >&>sz, 


344 


FIG.  163. 


FIG.   164. 


3 ., 

fe • 

: ass • 

-'JB ...... 


5 

__ a 


Thp  mutual  n  lal         of  the 

to  the  Bagmenta  In  til 

and  to  tke  exits  nf  the  Derves! 

(Qoweit). 


Bourgery's  outine  later.il  view  anatomical  diagram  of  the  cerebro- 
spinal axis  or  neiraxis.  from  Quain's  anatomy,  showing  the  cerebro-spfnal 
cavity  ttoTi  the  top  of  the  brain  with  the  cranium  to  the  end  of  the  spinal 
cord,  cauda  equina  and  corcyx.  F,  T  and  O  are  the  frontal,  temporal  and  oc- 
cipital lobes  ot  the  cereorum;  C.  P  and  Mo  are  the  cerebellum  pons  Varolii 
and  medu.la  oblongata;  M  and  Ms  show  the  upper  and  lower  extremities  of 
the  soinal  cord;  Ce.  the  cauda  equina  at  the  lower  end  of  the  spine  be- 
ginning with  tne  last  lunnar  spinous;  V,  ganglion  of  the  fifth  nerve 
or  the  trigeminal,  or  ganglion  of  Gasser  with  its  three  branches  faintly 
shswn;  Cl  shovs  the  tirst  of  the  spinal  nerves  or  first  cervical  coming 
out  under  tie  occiput,  a  'd  Cvm  is  the  last  or  lowest  cervical;  DI  is  the 
first  djrsal  or  thori:i;  and  D.XII  is  the  twelfth  or  lowest  and  last  dorsal.  The 
first  sacral  nerve  begins  at  S  ;  Sv  is  the  fifth  sacral;  S  is  the  sacral  plexus 
and  Col  is  the  coccygeal  nerve. 


CHAPTER  XXIX. 


THE    NEURAXIS    AGAIN,    DIAGNOSTICALLY    VIEWED. 


A  CURSORY  DEMONSTRATION  OF    CRANIAL  NERVES— THE  COLUMNS   OF 
THE  SPINAL  CORD  AND  THE   NERVES    THAT  GO  TO  AND  COME 
FROM   IT— THE  CORD   SEGMENTS  OF  IMPRESSION  AND   IN- 
FLUENCE—OUTLINE  OF    THE    CEREBRAL   AND  SPINAL 
NERVES  AND   NERVE  CENTERS  AND  THEIR  RELA- 
TION TO  NERVOUS   DISEASES. 

To  fasten  this  important  matter  firmly  in  your  minds, 
we  introduce  again  Bourgery's  outline  lateral  view  anatom- 
ical diagram  of  the  cerebro-spinal  axis  or  neuraxis  from 
Quain's  anatomy  (Fig.  163)  its  relations  to  the  cerebro- 
spinal cavity,  from  the  upper  infeiior  surface  of  the  cra- 
nium to  the  coccyx,  and  an  illustration  of  the  under  surface 
of  the  brain,  the  crura  cerebri,  pons  Varolii,  medulla  ob- 
longata, showing  apparent  or  external  cerebral  nerve  exits, 
together  with  a  brief  outline  of  the  spinal  nerve  origins. 

F  T  O  are  the  frontal,  temporal  and  occipital  lobes 
of  the  cerebrum.  G  P  and  M  O  are  respectively  the 
cerebrum  and  pons  Varolii,  medulla  oblongata;  Ms,  Ms  show 
the  median  line  above  and  belcw  of  the  spine;  Ce,  shows 
the  cauda  equina  at  lower  end  of  the  spine  beginning  with 
the  last  lumbar  spinous  process;  V,  if  you  scan  it  closely, 
shows  the  ganglion   of  the  fifth  nerve,  otherwise  called    the 

[345] 


34  i 

trigeminal  ganglion  or  ganglion  of  Gasser,  with  its  three 
brandies  faintly  shown.  Now  look  at  the  base  of  the  brain 
and  the  fifth  nerve  bore.  This  nerve  is  the  seat  of  an 
often  trying  and  sometimes  intractable  and  excruciatingly 
painful  trouble  called  prosopalgia,  tic  douloureux,  trigemi- 
nal or  t ri  -  facial  neuraglia,  its  diagnostic  characteristic  being 
a  paroxysmal  pain,  passing  along  the  course  of  the  branches 
or  twigs  of  this  nerve  and  suddenly  changing,  often  from 
one  branch  to  another. 

This  is  the  large  nerve  that  I  have  often  demonstrated 
as  seeming  to  sprout  out  from  either  side  of  this  beautiful 
bridge,  about  the  middle  of  .it,  as  we  look  across  from  be- 
fore backward,  more  beautifully  curved  and  delicately  and 
strongly  constructed  for  its  wondrous  purpo.-es  tl  an  any 
bridge  of  man's  contrivance,  as  the  poets  have  described  it. 

The  origins  of  these  nerves  are  deeper  down  from  the 
nuclei  in  the  floor  of  the  fourth  ventricle  on  opposite  sides, 
(from  whence  so  many  other  of  the  cranial  nerves  arise), 
eight  of  the  twelve  nerves  of  the  brain,  leaving  out  only 
the  fourth,  third,  second  and  first  pairs.  The  nerves  of  the 
brain  seem  like  the  twelve  apostles,  to  have  one  chief  end 
in  view,  namely:  the  salvation  and  service  of  the  soul  of 
the  human  organism,  that  is  the  neurone  centers  of  the 
brain. 

If  you  look  a  little  farther  beyond  the  pons  Varolii,  fol- 
lowing these  two  roots  till  we  reach  the  pars  petrosa  ossa 
temporalis,  as  they  say  over  in  Berlin,  but  as  we  say  in 
English,  as  far  as  the  petrous  or  especially  hard  portion  of 
the  temporal  bone,  we  find  a  lump  or  enlargement  or 
igl.ion  developed  in  the  sensory  root,  after  the  manner  of 
the  ganglions  on  posterior  sensory  roots  of  the  spinal 
nerves.  This  expansion  or  ganglion  may  be  likened  to 
the     stubby     trunk    of    a    palm    tree    with    three    principal 


347 

branches,  one  the  ophthalmic  nerve  going  to  the  eye  and  its 
vicinity  (lachrymal,  palatin,  nasal)  branches  with  numerous 
sub-divisions,  another  going  to  the  teeth  and  mucous  mem- 
„branes  of  the  upper  jaw  and  face,  the  superior  maxillary, 
and  the  third,  the  inferior  maxillary,  going  to  the  cheeks, 
teeth,  temple    and  tongue  and  many  facial  muscles. 

We  will  not  present  in  minute  detail  all  of  the  distri- 
butions of  this  nerve.  It  is  in  one  of  its  branches  only  a 
compound  or  motor  and  sensory  nerve.  The  combined 
sensory  and  motor  branch  is  the  inferior  maxillary  nerve. 
The  ophthalmic  and  upper  maxillary  branches  are  only  sen- 
sory. You  will  need  to  keep  handy  for  purposes  of  diag- 
nosis, accurate  anatomical  tables  like  those  in  some  of  your 
text-books  or  in  Flower's  diagrams.  If  you  do  not  you  will 
get  the  origins,  distributions  and  functions  of  the  fifth  and 
seventh  nerves  mixed.  This  might  result  disastrously,  es- 
pecially in  the  practice  of  surgery,  as  it  did  once  in  the 
practice  of  that  eminent  surgeon,  Sir  Charles  Bell,  giving 
the  profession  as  a  result  a  more  intimate  knowledge  of 
that  distorting  form  of  seventh  nerve  or  facial  paralysis, 
called  after  the  great  surgeon's  mistake  in  cutting  the  fa- 
cia! for  the  tri-facial  in  a  case  of  tic  douloureux,  Bell's  palsy 
or  Bell's  paralysis,  that  form  of  palsy  resulting. 

A  man's  blunder  sometimes  makes  him  famous  as 
well  as  his  successes  and  we  always  think  of  Sir  Charles 
when  we  see  a  poor  devil  who  used  to  whistle,  but  who  can 
no  longer  pucker  his  mouth  (for  that  ordinarily  distress- 
ful performance  to  unwilling  auditors),  and  one  of  whose  eyes 
stands  wide  open  when  lie  would  close  them  both  at  your 
request,  if  he  could,  and  whose  mouth  draws  to  the  oppo- 
site side  of  the  victim's  face  when  he  tries  to  speak.  We 
know  Sir  Charles  Bell  by  the  facial  palsy  he  unwittingly 
demonstrated,  better  than    we  know  him  by  the  respiratory 


348 

nerves  that  bear  his  name,  and  quite  as  well  as  we  know 
him  as  the  discoverer  of  the  motor  and  sensory  nerves  as 
separate  nerves  of  the  cord.  The  tri- facial  nerve  is  a  fa- 
cial nerve  as  you  also  see,  as  well  as  the  seventh  nerve.  It 
supplies  the  skin  of  the  face  chiefly.  It  supplies  the  cornea, 
mucous  membrane  of  mouth  and  nose  and  dura  mater,  with 
fibers  of  sensation.  Its  branches  supply  the  skin  of  the 
cheeks,  lips,  chin  and  temples  and  anterior  part  of  the  sur- 
face of  the  tongue.  As  a  motor  nerve  it  has  more  to  do 
with  the  movement  of  the  lower  half  of  the  face  than  its 
prototype,  the  facial  or  seventh  nerve.  The  fifth  nerve  motor 
brandies  move  the  muscles  of  mastication,  the  masseters, 
the  temporals,  the  pterygoid,  the  stylohyoid  and  the  anterior 
belly  of  the  digastric  muscles.  The  tri -facial  nerve  or 
fifth  nerve  is  more  of  a  sensory  nerve  than  a  motor.  The 
facial  or  seventh  nerve  is  more  of  a  nerve  of  motion,  for 
the  expressions  of  the  face  especially.  It  has  been  called 
the  mimic  nerve  of  the  face. 

The  fifth  nerve  has  ganglionic  relations  other  than  with 
the  Gasserian  ganglion,  viz:  The  ophthalmic,  lenticular  or 
ciliary  ganglion,  Meckel's  or  the  spheno-palatin  ganglion,  the 
otic  and  the  sub-maxillary.  All  connection  with  the  fifth 
nerve  is  by  the  sensory  root,  an  important  thing  to  remem- 
ber, for  when  sensation  dies  in  the  root,  connection  is  nil. 
The  otic,  Meckel  and  submaxillary  ganglions  have  motor 
connection  with  the  seventh  or  facial  nerve  and  the  ciliary 
or  ophthalmic  with  the  third  nerve,  while  filaments  from  a 
vaso-motor  sympathetic  plexus  go  to  all  of  these  ganglia. 
We  feel  most  with  the  fifth  nerve  about  the  face,  and  sen- 
sory nervous  diseases  belong,  like  toothache  and  neuralgia, 
especially  to  it.  We  express  most  with  the  seventh.  It 
is  a  nerve  of  facial  mimicry,  pantomime  and  facial  expres- 
sion.      It   is  the  chief  seat  of    faeial    paralysrs,  palsies    and 


340 

tics,  facial  tremors,  through  close  sympathetic  relations  with 
the  fifth. 

The  fifth  nerve  is  a  wonderful  nerve,  the  seventh  is 
likewise.  Here  is  the  seventh  clear  across  the  Varolian 
bridge,  coming  out  from  the  lower  under  surface  of  the 
bridge,  from  between  the  restiform  and  olivary  bodies.  So 
also  are  the  sixth  or  motor  oculi  externus  or  abducens 
nerves  next  to  it.  When  they  are  paralyzed  the  eyeball 
can  not  be  turned  outward.  They  come  from  under  the 
bridge,  too,  between  the  bridge  and  the  tops  of  the  pyramid 
on  either  side  of  the  median  line.  Here  is  the  fifth  com- 
ing from  the  middle  of  the  side  of  the  bridge  almost  in  a 
direct  line,  antero-posteriorly  with  the  fourth  or  pathetic 
nerve  which  comes  out  from  under  the  bridge,  too,  but  su- 
periorly where  the  outer  line  of  the  crus  cerebri  or  brain 
leg  passes  downward  with  its  many  fibers  of  motion  and 
sensation  under  the  bridge  to  the  cord  and  other  connec- 
tions. It  comes  from  under  the  bridge,  not  from  the  fourth 
ventricle  where  eight  of  its  neural  companions  originate,  but 
from  the  way  there,  from  the  acqueduct  of  Fallopius,  not 
like  the  Appian  way  from  Rome  to  Brundesium,  paved  with 
stones  by  a  great  Caesar's  command,  but  paved  by  a  greater 
than  any  Roman  Emperor,  and  with  precious  neurones,  which 
are  the  centers  of  life  and  neural  power,  the  way  from  the 
third  to  the  fourth  ventricle,  iter  a  tertio  ad  quarium  ven- 
triculum.  This  passage  way  between  the  third  and  fourth 
ventricles  gives  origin  to  the  fourth  cranial  nerve. 

But  yet  another  cranial  nerve,  the  third  or  motor 
communis,  arises  deep-seated  from  the  floor  of  the  Sylvian 
way  or  acqueduct  of  Sylvius  and  here  it  is,  nestled  here  be- 
tween the  crura  of  the  brain,  where  they  appear  to  join  in 
the  median  line  anterior  to  the  pons  to  pass  under  the 
bridge    and  go    down  the    spinal    cord.     And    a    wonderful 


350 

nerve  too  is  this  common    motor    oculi.      It  has    wonderful 

motor  connections  and  receives  fibers  from  the  cavern- 
ous plexus  of  the    sympathetic. 

We  have  seen  already  that  it  lias  connection  with  the 
ciliary  ganglion  and  it  is  through  this  relation  that  it  reaches 
the  ciliary  muscle  and  has  power  to  contract  the  pupil.  It 
is  the  sphincter  pupillae  muscle  nerve  of  your  anatomies. 
It  connects  with  and  innervates  all  the  rotary  muscles  of 
the  eye  except  the  superior  oblique  and  external    rectus. 

Wonderful  nerves  are  these  eye -moving  nerves.  They 
move  the  hearts  of  man  and  woman  figuratively,  not  ana- 
tomically speaking,  except  only  retlexly  from  the  brain  and 
mind  and  they  move  the  world,  not  with  an  Archimedian 
lever,  but  by  means  of  men  and  minds  influenced  through 
their  movements.  But  we  shall  recur  to  these  nerves  and 
other  of  the  cerebral  nerves  again  and  again.  They  and 
the  others  of  the  twelve,  have  much  to  do  with  our  ability 
to  diagnosticate  what  is  going  on  in  the  brain  when  disease 
attacks  this  important,  commanding,  superior  part  of  the 
neuraxis. 

Let  us  go  forward  before  *ve  leave  the  subject  to  the 
two  brain  nerves  that  have  no  connection  with  either  the 
third  or  fourth  ventricle  or  the  iter,  viz:  the  first  and  the 
second.  Here  is  the  nerve  of  smell  which  we  test  with 
odors  for  anosmia,  hyperosmia  and  other  defects  of  smell  in 
trying  to  make  our  diagnosis.  These  are  often  damaged  in 
function  when  the  anterior  median  under  surface  of  the  brain 
is  diseased.  Its  origins  are  here  in  the  anterior  and  middle 
lobes  and  in  this  perforated  space.  The  fifth  nerve,  as  we 
have  seen,  has  two  roots  and  three  branches,  but  this  has 
three  roots  and  branches  down  into  the  nasal  cavity  walls 
like  the  hairs  of  a  dusting  brush.  Here  is  the  optic  or  sight 
nerve,  with  its  crossing   fibers  making  the    crossing,  or  de- 


351 

cussation,  as  it  is  called  in  the  chiasm.  It  also  has  non-decus- 
sating or  non-crossing  or  lateral  fibers,  going  back  to  find  final- 
connection  with  the  occipital  lobes,  but  connecting  on  their 
way  with  the  corpora  quadrigemina  and  optic  thalamus  here. 
Here  is  the  eighth  or  auditory  nerve,  one  of  the  eight 
cranial  nerves  coming  from  the  fourth  ventricle.  It  goes  to 
the  internal  ear.  It  joins  the  facial  in  giving  off  a  filament, 
which,  blended  with  that  of  the  facial,  makes  up  the  nerve 
of  Wrisburg,  the  chief  source  and  origin  of  the  chorda  tym- 
pani.  Here  is  the  ninth  or  glosso-pharyngeal  coming  from 
the  fourth  ventricle  and  going  to  the  posterior  third  of  the 
tongue,  the  seventh  nerves  here  supply  the  anterior  two- 
thirds  of  the  organ.*  Here  is  the  vagus,  that  vagrant  nerve 
which  wanders  to  the  larynx,  aesophagus,  lungs,  heart,  stom- 
ach, intestines,  liver,  kidneys  and  supra  renal  capsules  and 
spleen  and  is  often  in  evidence  clinically  and  diagnostically, 
as  when  it  is  irritated,  the  heart  is  abnormally  slow  or  par- 
alyzed. And  it  is  the  heart  movements  and  the  respirations 
that  are,  in  consequence,  abnormally  fast  or  cease  altogether. 
Here  are  the  accessories  supplying  the  sterno-mastoidii  and 
trapezii,  as  evidenced  in  wry  neck  or  scapular  palsy  or 
spasm,  and  the  hypoglossus  that  moves  the  tongue  drawing 
it  toward  the  paralyzed  side  when  it  is  paralyzed.  It  inner- 
vates for  motion  the  genio-glossus,  hyoglossus,  genio-hyoid, 
omohyoid,  hyothyroid,  sternothyroid  muscles.  It  has  a  good 
deal  to  do  with  keeping  up  appearances  about  the  tongue 
and  throat.     Vide  Figs.   162  et  sequitur. 

*These  two  tongue  nerves,  when  diseased  at  their  distributions,  or  along-  their  course, 
give  abnormal  sensations  of  taste  or  pyraguesias.  When  destroyed  in  their  course,  distri- 
butions or  at  their  origins,  taste  is  destroyed.  This  condition  is  technically  termed  aguesia. 
Hemilingual  aguesia  sometimes  results  from  central  bulbar  causes  like  hemiglossoplegia. 
Hemiaguesia  sometimes  results,  like  hemianaesthesia,  from  hysteria.  It  may  result  from  a 
unilateral  organic  brain  disease  involving  the  bulbar  origins  of  either  the  ninth  or  seventh 
nerves  or  from  disease  of  the  cortical  center  for  the  sense  of  taste  in  the  tempero-sphenoidal 
lobe  area.  Aguesia  of  the  anterior  two-thirds  of  the  tongue  points  to  facial  nerve  per- 
ipheral or  central  morbid  implication;  of  the  posterior  third  of  the  tongue  to  glossopharyn- 
geal, or  ninth  nerve,  course  or  center  involvement.  When  the  glossopharyngeal  aguesia 
appears,  the  soft  palate  and  pillars  of  the  fauces  become  synchronously  involved, If  the 
cause  of  the  trouble  is  central.  As  aguesia  without  peripheral  lesion  of  either  the  seventh  or 
ninth  nerve  points  to  central  disease  and  paraguesia  to  mouth  and  stomach  perversion,  so 
psychical  paraguesia  maybe  a  symptom  of  hysteria  or  insanity,  the  perversion  of  taste, 
l.ke  anosmia  being  in  the  psychic  centers  and  due  to  cerebral  disease. 


CHAPTER    XXX. 

OUTLINE    OF  THE  CEREBRAL  AND    SPINAL   NERVES  AND    NERVE    CENTERS 
AND   THEIR   RELATION   TO   NERVOUS   DISEASES,    ETC,  CONTINUED. 


Laying  aside  this  brain  and  resuming  our  description  of 
this  antero-posterior  longitudinal  hemi-section  of  the  cer- 
ebro-spinal  axis  we  have  here  (Fig.  163)  at  OI,  the  first 
of  the  spinal  nerves  or  first  cervical  coming  out  here  under 
the  occiput  and  VIII  is  the  last  or  lowest  cervical.  Bl  is 
the  first  dorsal  or  thoracic  and  DX1I  is  the  lowest  and  last 
dorsal.  The  first  sacral  nerve  begins  here  at  SI;  Sv  is  the 
fifth;    S  is  the  sacral  plexus  and  COI  is  the  coccygeal  nerve. 

The  surrounding  parts,  as  you  see,  belong  to  the  bony 
encasement  of  this  great  nerve  center  bony  canal,  made  up 
of  the  cervical,  dorsal  and  lumbar  vertebrae  with  their  bod- 
ies in  front,  spinous  processes  behind  and  continuous 
canals  in  close  and  marvelous  relation  for  the  protection, 
holding  and  transmission  of  the  spinal  cord  between;  the 
basin-shaped  pelvis,  being,  as  its  name  implies,  the  basin 
floor  of  this  great  nerve  center  column,  the  cranial  vault 
resting  like  a  dome  or  cupola  on   top. 

The  spinal  cord  is  the  flatfish  cylindroidal  continuation 
of  the  medulla  oblongata  into  the  vertebral  canal,  enclosed 
in  the  theca  vertebralis  or  vertebral  sheath  and  ex- 
tending to  the  level  of  the  lower  border  of  the  first 
lumbar    vertebra;    here  it    suddenly  narrows    to  a    terminal 

[352] 


353 

cone  (conus  terminalis)  which  tapers  to  a  slender  glisten- 
ing terminal  strand  {filiim  terminate),  in  the  center  of  the 
cauda  equina,  traceable  as  far  as  the  third  sacral  vertebra. 
From  each  side  of  the  spinal  cord  arise  the  thirty-one  pairs 
of  spinal  nerves,  which  leave  the  vertebral  canal  through 
the  inter-vertebral  foramina.* 

The  female  cord  more  often  than  the  male  reaches  to 
the  second  lumbar  vertebra.  That  woman  (with  a  smaller 
brain)  should  have  a  longer  cord  than  man  may  be  due  to  the 
extra  pelvic  demands  upon  her  cord  centers. 

The  levels  of  escape  from  the  cord  of  the  various 
spinal  nerves  vary,  as  we  may  see  by  Gowers'    table. 

The  cord  contracts  at  the  medulla  oblongata,  widens 
from  the  second  cervical  to  the  first  dorsal  vertebra,  again 
contracts  from  this  point  to  the  eleventh  dorsal,  where  it 
again  dilates,  to  narrow  again  at  the  top  of  the  first  lumbar 
vertebra.  The  upper  is  the  cervical  enlargement,  the  lower 
the  lumbar  enlargement.     Its  general  form  is  cylindrical. 

"The  spinal  nerves  are  connected  to  the  spinal  cord 
by  two  roots  (Fig.  139)  one  of  which,  the  efferent  or  motor, 
(5),  arises  from  the  anterior  aspect  of  the  cord;  the  other, 
the  afferent  or  sensory  (6,  Fig.  139)  is  connected  with  the 
posterior  surface.  After  a  short,  independent  course  and 
the  development  of  a  ganglion  (6,  Fig.  139)  which  is,  there- 
fore, a  mixed  nerve,  containing  both  afferent  and  efferent 
nerves.  The  nerves  distribute  themselves  by  minute  rami- 
fications to  the  receptive  organs  and  the  periphery,  each 
filament   remaining   distinct    in    its    own    course. 

*The  average  dimensions  of  the  cord  are  as  follows: 

Male  length,  43  cm.-  Volume  34  ccm.;  weight,  34  grammes. 
Female  "        40   "  "        30     "  "        29 

Motion  of  the  vertebral  column  does  not  appreciably  affect  the  level  of  the  end  of 
the  cord.  The  foetal  cord  extended  originally  the  whole  length  of  the  spinal  canal, 
but  the  vertebral  column  begins  to  outgrow  it  at  the  tenth  week,  and  by  the  time  of  birth 
the  cord  only  reaches  as  far  as  the  second  lumbar  vertebra.  The  outgoing  nerves  which 
at  first  passed  horizontally  outward  to  their  respective  metameres,  become  more  and  more 
oblique  and  retracted  within  the  theca,  owing  to  the  inequality  of  growth. 


354 

The  spinal  cord  itself  consists  of  central  gray  matter 
and  white  columns  or  strands.  The  gray  matter  has  the 
form  of  a  double  crescent  with  the  convex  surfaces  joined 
by  commissures,  in  the  center  of  which  the  central  canal  of 
the  spinal  cord  is  seen  (9),  and  the  horns  of  the  crescents 
are  connected  respectively  with  the  anterior  and  posterior 
roots  of  the  spinal  nerves. 

The  cells  of  the  anterior  cornu  are  large  and  multi- 
polar, those  of  the  posterior  small,  and  mingled  with 
what  is  termed  gelatinous  substance.  The  conducting 
strands  form  the  great  divisions  or  columns,  the  anterior, 
the  lateral  and  posterior.  (See  description  of  Figs.  139, 
146,   147  and   148.) 

The  efferent  or  motor  impulses  pass  down  and  from 
the  cord  along  the  motor  nerves,  chiefly  on  the  sides  from 
which  the  roots  emerge.  Hence  a  tumor  pressure  disease 
on  one  side  of  the  cord  or  hemi-section,  causes  paralysis  of 
motion  chiefly  on  the  same  side  of  the  body,  in  the  parts 
below  the  section. 

The  sensory  or  afferent  impressions  are  received  by  the 
cord  and  conveyed  up  to  the  brain  chiefly  in  the  opposite 
half  of  the  cord  to  that  into  which  the  sensory  root  sinks. 
Hemi-section  of  the  spinal  cord  causes  loss  of  sensation  on 
the  opposite  side  of  the  body  in  all  parts  below  the  sec- 
tion; increase  of  sensibility  and  paralysis  on  the  same  side 
as  the  lesion. 

The  antero-lateral  columns  of  the  cord  are  the  chief 
motor  paths.  A  certain  injury  or  disease  of  one  side  of  the 
spinal  cord  not  involving  the  brain,  causes  that  form  of  par- 
alysis of  motion  on  one  side  and  sensation  on  the  other 
side  known  as  Brown-Sequard's  paralysis,  illustrated  in  this 
diagram.     (See  Brissaud's  diagram.) 

The    cerebro-spinal    axis,  at    the    top    of  which    is    the 


355 

brain,  is  brought  into  harmonious  touch  in  health  and  into 
inharmonious  touch  in  disease  with  its  environment,  within 
as  well  as  without  the  body,  by  means  of  the  twelve  cra- 
nial and  thirty-one  pairs  of  spinal  nerves  whose  origins  are 
shown  in  the  illustrations  under  the  head  of  neuraxis  or 
cerebro-spinal  axis. 

These  nerves,  as  we  have  seen,  are  afferent  and  sen- 
sory, i.  e.,  conveying  impressions  to  the  cerebro-spinal  axis, 
(which  includes  the  brain),  and  efferent  or  motor,  carrying 
impressions  or  expressions  outward. 

This  nervous  arrangement  makes  up  the  sensory  and 
motor  nervous  systems,  as  it  is  combinedly  called.  The 
sensory  nerves  of  this  system,  carrying  impulses  directly  to 
he  brain,  by  means  of  the  twelve  pairs  of  cranial  nerves 
and  directly  to  the  spinal  cord  and  indirectly  up  to  the  brain 
areas  of  the  neuraxis,  may  be  likened  to  the  dendrites  and 
neuraxones  of  the  nervous  syslem,  as  we  have  said;  the 
cellulipetal  influence  going  to  the  cell  or  neurone  center  or 
cord  center  and  the  cellulifugal  nerve  influence  conducting 
paths,  carrying  impressions  away  from  the  spinal  cord  seg- 
ment or  the  neurone  center.  The  terms  sensory  and  mo- 
tor embrace  all  the  action  probably  belonging  to  these  two 
means  of  communication  of  nerves  center  with  periphery, 
viz.:  feeling  or  motion,  or  sensation  and  impression.  Sensory 
impressions  from  the  place  of  peripheral  destination  and 
motor  stimuli  from  the  point  of  origin  of  these  nerve  con- 
connections  and  relations,  make  up  the  whole  of  their 
function,  beside  the  work  which  is  done  in  the  neurones 
themselves  that  constitute  in  aggregate   the  nerve  centers. 

The  work  of  the  central  neurones  is  to  receive  and  send 
on  unchanged,  or  to  change  into  motor  impulse  and  send  out 
or  to  elaborate  and  otherwise  transform  peripheral  impres- 
sions, as  in  the  reflexes  of  the  spine  and  medulla  or  of  the 


356 

eye,  nose  or  ear,  or  to  inhibit  or  arrest  impressions,  as  in 
the  vagus  center,  over  the  movements  of  the  heart  and  the 
higher  but  similar  movements  of  reflection  and  deliberation 
in  the  exalted  mind  centers  of  the  gray  cortex  of  the  brain, 
that  grand  grouping  of  psychic  neurones  which  makes  the 
brain  of  man  the  temple  of  thought  and  the  palace  of  the 
soul. 

FIG.   165. 


Fibers  of  the  direct  pyramidal  tract  conduct  inhibitory  influences  to 
the  motor  neurones  of  the  anterior  horns.  When  they  are  damaged  in  paral- 
ysis, spastic  or  spasmodic  states  appear,  going  out  from  the  cord. 


Because  of  the  fact  that  after  destruction  of  considerable 
areas  of  the  lateral  columns,  neither  motion  nor  sensation  is 
absolutely  paralyzed  in  any  particular  part,  it  has  been 
maintained  for  the  spinal  cord,  as  it  has  been  for  the  brain, 
that  a  vicarious  interchange  of  function  exists  between  dif- 
ferent parts  of  the  cord.  And  there  is  some  truth  in  this, 
but  the  variation  is  not  sufficient  to  invalidate  the  general 
law.  Above  the  foramen  magnum  the  spinal  cord  becomes 
the  medulla  oblongata,  which    we  will  discuss    as  a   part  of 


357 

the  neuraxis  in  connection  with  the  brain,  it  being  usually 
described  by  anatomists  as  a  part  thereof.  The  brain  or 
encephalon,  includes  all  the  cerebral  mass  within  the  cra- 
nial walls  and  above  the  foramen  magnum  cranii. 

The  gray  matter  of  the  spinal  cord  is,  as  you  see,  cen- 
tral or  internal  in  relation  to  the  white.  The  reverse  exists 
in  the  brain,  the  gray  matter  being  external.  The  nerves 
of  the  brain  and  cord  are  white;  conducting  nerve  tissue 
is  generally  white.  Nerve  matter  in  gross,  that  which  re- 
ceives, originates,  generates,  elaborates,  arrests  or  decides 
nerve  function,  is  generally  gray,  so  far  as  we  know.  The 
white  matter  waits  upon  the  gray  and  carries  its  messages 
of  sensation  or  impression  to  the  gray  centers  and  receives 
from  them  its  commands. 

The  upper  and  mid-dorsal  regions  of  the  cord  are  the 
favorite  seats  of  Brown-Sequard  paralysis.  The  leg  will  be 
motorially  useless  on  the  side  of  the  injury,  with  increased 
patellar  reflex,  (sometimes  lost  reflex  on  the  same  side),  cu- 
taneous hyperesthesia,  hyperalgesia;  loss  of  muscular  sense 
with  anesthesia  and  analgesia  on  the  opposite  side  and  the 
muscular  sense  on  the  side  of  injury  intact. 

If  the  source  of  this  paralysis  is  in  the  cervical  region, 
it  causes  hemiplegia,  that  is,  paralysis  of  the  leg  and  arrr. 
on  the  same  side  and  anesthesia  of  the  opposite  leg  and 
trunk.  In  a  one-sided  lesion  of  the  cord,  in  the  sacral  re- 
gion of  the  cord  very  low  down,  sacral  paralysis  of  sensa- 
tion and  motion  are  on  the  side  of  the  lesion,  because  very 
few  sensory  fibers  belong  to  the  other  side,  as  this  illustra- 
tion of  Brissaud  shows.     (Fig.   166.) 

Paralytic  disease  located  high  up  in  the  brain  on  one 
side  causes  opposite  loss  of  motion  with  or  without  loss  of 
sensation  on  the  opposite  side,  according  to  its  extent  or  lo- 
cation.    Suspect  paralysis  of  brain  origin  when  you  have  a 


358 

sudden  loss  of  consciousness  and  loss  of  power  of  motion 
on  the  opposite  side  of  the  body,  persisting  after  return  of 
consciousness.  Suspect  Brown-Sequard  paralysis  when  be- 
low the  neck  you  have  loss  of  motion  on  one  side  and  loss 
of  sensation  on  the  other,  without  history  of  sudden  loss  of 
consciousness. 


FIG.    166. 


cvoA&We  uxv^oXfcxoV  Gcrc& 


359 
THE    RAILWAY    NEURAXIS. 

This  psycho-neurosis  may  result  from  the  shock  of  rail- 
way accidents,  or  from  the  repeated  shocks  to  the  head  and 
cord  neurones,  received  by  railway  employes  long  in  rail- 
way service,  short  of  those  extreme  degrees  of  injury  caused 
by  fractured  cranial  bones  or  dislocated  vertebrae.  The 
over  mental  strain  of  too  long  hours  of  an  excessively 
exacting  and  vigilant  service,  gives  the  neurones  too  little 
rest  and  sleep  for  perfect  recuperation  in  many  departments 
of  modern  railway  work.  Too  constant  psychic  neurone 
service  is  exacted  of  the  brain,  and  after  a  time  the 
central  capital  of  reserve  force  is  exhausted  and  collapse 
comes  from  causes  which,  in  the  beginning,  would  not 
break   the    brain. 

The  principal  symptoms  are  an  impaired  nerve  tone, 
apepsia  nervosa,  intestinal  atony,  insomnia  and  sensory 
disturbances,  cerebral  and  medullary  hyperaesthesia,  peri- 
pheral anaesthesia  and  other  impaired  sensory  perceptions, 
facial  tics  and  spasms,  mfmory  failure  and  the  mental  de- 
bility and  timidity  of  neurasthenia.  The  power  of  extract- 
ing nutrition  from  the  blood  to  adequately  sustain  the 
normal  mental  spontaneity  and  neurone  vigor  of  action  has 
become  impaired.  Metabolism  is  changed  by  shock  and 
the  apathy,  irresolution  and  morbid  apprehensions  ofneura- 
trophia  and  neurasthenia  have  settled  upon  the  psychic 
neurones.  The  condition  appears  to  be  one  of  cerebro- 
spinal shock  and  consequent  retrograde  change  and  cere- 
bral and  spinal  neurasthenia,  in  which  the  nutrition  and 
tone  of  the  neurones  of  the  neuraxis  is  changed. 

The  modern  rapid  transit,  jerkily  moving  and  often  too 
suddenly  stopped  street  car, and  sky-scraper  building  elevator, 
may  cause  the  same  condition  of  the  brain  and  spinal  cord. 


360 

NERVOl'S   INI  !  UENCE   IN   CAUSING  HEMORRHAGE 
AND  NEURAXIS  HEAT. 

Traumatisms  and  grave  shocks  of  the  spinal  cord  and 
brain  may  cause  increase  of  temperature,  but  so  ordinarily 
does  any  great  violence  to  the  cerebro-spinal  axis  or  to  the 
viscera  connected  with  the  neuraxis.  Excitation  of  the 
motor  area  for  the  leg  and  thigh  of  one  cerebral  hemisphere 
has  caused  increase  of  temperature  in  the  limb  supplied  by 
the  descending  decussating  fibers  to  the  opposite  limb,  but 
the  rabbit  and  dog  experiments  by  brain  excitation  usually 
give  rise  to  general  elevation  of  temperatuie.  It  is  not 
strange,  therefore,  that  various  sections  of  the  brain  base 
should  cause  rise  of  temperature.  Schreiber's  section  of 
the  medulla  where  it  joins  the  cord  causing  increased  brain 
heat. in  the  pons,  is  not,  therefore,  remarkable. 

H.  C.  Wood,  an  eminent  American  neurologist,  conjec- 
tured the  existence  of  heat  centers  in  the  brain  many 
years  ago.  Isaac  Ott,  whom  1  have  already  mentioned, 
in  1884  located  heat  centers  definitely  in  the  corpora 
striata  of  rabbits;  in  the  following  year  he  found  heat  cen- 
ters in  the  optic  thalami.  Sachs  and  Aronsohn  have 
confirmed  Ott's  experimental  conclusions,  while  Richet,  a 
Frenchman,  found  a  heat  center  in  the  anterior  part  of  the 
brain  and  Tscheschichm,  a  Russian,  found  one  above  the 
pons.  These,  as  well  as  Budge,  Tussana  and  Christiana, 
according  to  the  studies  of  my  lamented  friend,  Landon 
Carter  Gray,  have  found  the  brain  to  be  a  source  of  heat 
elevation  under  traumatism.  {Vide  article  Heat  Centers,  L 
C.  Gray's  Nervous  and  Mental  Diseases.) 

Hemorrhages    have    been    found    in  the  viscera,  lungs, 
stomach,  kidneys,  etc.,  after  injuries    to  the    basal    ganglia, 


361 

crura  cerebri  and  medulla,  and  after  violent  concussion 
without    injury. 

The  experiments  quoted  show  that  heat  is  generated  by- 
nervous  influence.  Through  these  thermogenic  centers  we 
have  a  neural  as  well  as  chemical  heat  phenomenon  in 
animal  organism.  Neither  what  1  may  tell  you  nor  what 
your  books  of  today  tell  you,  will  give  you  all  you  are  yet 
to  learn  in  life  concerning  neural  and  extra- neural  symp- 
tomatology and  semiology  connected  with  nervous  diseases. 
Some  of  you  are  probably  destined  to  make  a  name  and 
fame  for  yourselves  by  further  discovery  in  this  direction. 
1  wish  that  the  names  of  all  of  you  may  become  enrolled 
high  on  the  keystone  of  fame's  triumphal  arch  for  good 
work    done  in  this  direction. 

Some  railway  surgeons,  who  are  often  better  operators 
than  neurologists,  and  more  accustomed  to  seeing  and  treating 
those  sensible  injuries  patent  to  the  natural  eye,  where  a 
fractured  or  dislocated  bone  or  other  markedly  apparent 
wound  in  the  anatomy  calls  for  their  aid,  often  display  a 
real  or  affected  skepticism  as  to  the  possibility  of  the  neu- 
raxis  being  hurt  in  its  neurone  center  groups,  without  an 
appreciable  hole  or  other  mark  of  great  violence  in  the 
anatomy,  to  account  to  them  for  the  nervous  disturbance. 
They  are  doubting  Thomases  who  must  first  see  the  im- 
print of  the  nail  before  believing  in  the  possibility  of  the 
symptoms;  yet  true  surgery  with  all  great  surgeons  who  ob- 
serve and  think  beyond  the  mere  technique  of  their  art, 
recognizes  concussional  and  violent  straining  of  the  higher 
nerve  centers,  even  extreme  psychic  or  fright  shock,  as 
capable  of  suspending  and  damaging  central  nerve  function 
without  sensible  external  injury.  The  ready  explanation  of 
the  smaller- calibered  surgeons,  for  what  they  can  not  readily 
understand   among   the   traumatic    neuroses,  without    a  dis- 


362 

located  or  fractured  back  or  cracked  skull  or  profound  ec- 
chymosis,  especially  if  the  unfortunate  victim  be  a  woman, 
is  hysteria.  They  forget,  or  ignore,  or  mayhap  have  not 
vet  conceded  the  existence,  of  those  groups  of  neurones  in 
the  gray  substance  of  the  cord  which  constitute  centers  of 
trophic  influence  which  affect  the  motor,  sensory,  conduct- 
ing and  inhibitory  functions  of  the  cord.  But  1  cannot  here 
pursue  the  subject  further.  You  must,  at  your  leisure, 
consult  such  books  as  Erichsen  on  the  one  side  and  Page 
on  the  other.  Page  has  made  the  most  of  the  hysterical 
view,  and  hysteria,  in  those  who  have  the  latent  hysterical 
diathesis,  is  often  brought  out  into  full  action  when  it  other- 
wise might  have  been  dormant  for  life,  but  for  some  grave 
accident  or  powerfully  depressing,  neurone  depraving,  and 
instability  exciting,  psychical  impression.  But  in  such  a 
case  the  hysteria  itself  is  the  result  of  the  exciting  cause, 
and  if  this  cause  be  a  violent  accident,  we  may  justly  call 
it  traumatic  hysteria,  if  without  the  traumatism  it  would 
likely  have  remained  dormant.  If  the  hysteria  pre-existed 
in  the  woman  it  could  not  justly  be  called  traumatic  hysteria. 

The  sensori-motor tract  of  the  cerebro-spinal  axis  is  con- 
nected with  the  various  motor  displays  of  prehension,  limb, 
finger,  toe,  tongue  and  eye  sensation,  and  with  all  of  the 
reflexes,  spasm  and  other  forms  of  contracture,  normal  or 
abnormal,  such  as  those  of  morbus  Thomsenii,  post-hemi- 
plegic  paralysis,  chorea,  hysteria,  convulsions,  etc.  The 
tremulous  movements  of  extreme  nervous  fatigue,  of  paralysis 
agitans,  of  disseminated  sclerosis,  tic  douleureux  or  tri-facial 
neuralgia,  the  jerky  movements  of  chorea,  the  rhythmical 
movement  and  unfixed  digital  attitudes  of  athetosis,  etc. 

The  sensory  nervous  system  reveals  the  nerve  chan- 
nel paroxysmally  darting  pains  of  sciatic  and  other  neural- 
gias, and  the  lightning    pains  and  cincture    feeling  of   loco- 


363 

motor  ataxia.  It  reveals  to  us  the  anaesthesias,  the  hyper- 
esthesias, the  analgesias,  hyperalgesias  and  parasthesias 
in  various  forms  of  sensory  illusion  or  hallucination  and  the 
normal  and  abnormal  distance  points,  as  shown  in  healthy 
or  diseased  states  of  the  peripheral  or  sensory  nervous  sys- 
tem by  aesthesiometric  measurement.  The  cutaneously  dis- 
tributed sensory  nerves  reveal  different  appreciations  of  dis- 
tant points  in  a  straight  line  at  different  parts  of  the  skin 
surface,  as  we  showed  you  when  we  presented  that  instru- 
ment of  precision  in    sensory  diagnosis,  the  aesthesiometer. 

DR.    E.    H.    WEBER'S   ESTHESIOMETRIC    DISTANCE    POINT'S    TABLE. 

This  table  has  long  been  the  chief  esthesiometric  guide 
and  resource  of  practicing  neurologists  for  the  past  four 
decades.  It  was  first  incorporated  in  a  neurological  work 
in  this  country  by  that  eminent  pioneer  neurologist,  now 
deceased,  Dr.  Wm.  A.  Hammond,  in  his  treatise  on  the 
Diseases  of  the  Nervous  System. 

[From  Milller's  Physiology .] 

Point  of  the  tongue y2  a  line. 

Palmar  surface  of  the  third  finger ] 

Red  surface  of  the  lips 2  lines. 

Palmar  surface  of  second  finger 2  " 

Dorsal  surface  of  third  finger 3  " 

Tip  of  the  nose 3  " 

The  palm  over  the  heads  of  the  metacarpal  bones 3  " 

Dorsum  of  tongue,  one  inch  from  the  tip 4  " 

Part  of  the  lips  covered  by  the  skin 4  " 

Border  of  the  tongue,  one  inch  from  the  tip 4  " 

Metacarpal  bone  of  the  thumb 4  " 

Extremity  of  the  great  toe 5  " 

Dorsal  surface  of  the  second  finger 5  " 

Palm  of  the  hand 5  " 

Skin  of  the  cheek 5  " 

External  surface  of  the  eyelids 5  " 

Mucous  membrane  of  the  hard  palate 6  " 

Skin  over  the  anterior  surface  of  the  zygoma _  7  " 


364 

Plantar  surface  of  the  metatarsal  extremity  of  great  toe     7        lines. 

Dorsal  surface  of  the  first  finger 7 

On  the  dorsum  of  the  hand  over  the  heads  of  the  met- 
acarpal   bones 8 

Mucous  membrane  of  the  gums 9 

Skin  over  the  posterior  part  of  the  zygoma 10 

Lower  part  of  the  forehead 10 

Lower  part  of  the  occiput 12 

Back  of  the  hand 14 

Neck  under  the  lower  jaw 15 

Vertex -   15 

Skin  over  the  patella 16 

"  "        sacrum 18 

"  "       acromion — 18 

The  leg,  near  the  knee  and  foot 18 

Dorsum  of  the  foot,  near  the  toes 18 

The  skin  over  the  sternum 20 

"  "        five  upper  vertebra 24 

"  "         spine  near  the  occiput 24 

"       in  the  lumbar  region 24 

"  "    middle  of  the  neck 30 

"     over  the  middle  of  the  back 30 

The  middle  of  the  arm 30 

thigh 30 

For  convenience  of  reference  in  lesthesiometric  measure- 
ments this  table,  made  by  Dr.  E.  H.  Weber,  will  be 
especially  necessary  in  using  Sieveking's,  Seguin's,  Ham- 
mond's or  any  other  assthesiometer  except  my  own,  and 
may  serve  you  even  in  the  use  of  mine. 

You  will  find  in  the  museums  and  text-books  and  in  the 
excellent  casts  of  Dr.  Wm.  Fuller  and  in  the  descriptive 
illustrations  of  Ford  Robertson,  Bevan  Lewis  and  Morrison  and 
Barker,  which  1  have  so  often  shown  you  in  my  demonstra- 
tions on  the  brain  and  cord,  many  elucidatory  illustrations 
to  help  you  to  a  clean,  clear  comprehension  of  the  subjects 
necessary  for  you  to  understand.  Each  text-book  on  neu- 
rology possesses  some  special  peculiarity  of  description  or 
illustration.  Here  are  some  further  illustrations  germane  to 
our  present  subject  in  addition  to  those  already  shown. 


365 


FIG.   167. 


J2*s<s 


Surface  or  central  irritations  of  a  spinal  center,  as  of  the  cervical 
plexus  or  spinal  accessory,  may  cause  superficially  reflected  or  centrally 
transmitted  spasms  of  single  muscles,  giving  the  phenomenon  of  wry  neck 
similar  to  the  illustration  (Fig.  167),  which,  however,  is  not  the  typical 
wryneck,  that  being  caused  by  irritation  of  the  external  branch  of  the  spinal 
accessory,  while  the  figure  shows  contraction  of  the  splenius  capitis  coming 
from  involvement  of  the  cervical  plexus. 

The  brachial  plexus,  when  irritated  by  disease  or  injury,  may  show 
Duchenne's  scapula,  caused  by  rhomboid,  levator  scapulae  and  serratus 
magnus  spasm,  drawing  the  inferior  angle  of  the  scapula  downward. 

Many  forms  of  spasm  may  be  specially  studied  in  Ross,  Gowers  and 
others,  and  the  finger  and  hand  and  general  retractions  of  hysteria  may  be 
studied  at  your  leisure  in  the  classical  and  detailed  history  of  hysteria  by 
Charcot,  Richer,  Fere,  Bourneville  and  others,  if  1  do  not  reach  the  sub- 
ject in  a  special  lecture  on  nervous  contractures  before  the  session  shall 
have  ended. 


366 


DlAGRAll   "1    Till    Pneuuogastric    \M<   Spinal 
Accessor!     Nerves,     mint     connections    and 

BRANCHES.      (Fl'OUl  HERMANN'S  "  Physiol 

P,  Pncumogastric  nerve. 
S  \.  Spinal  ai  cessory  aei  \  >-. 
n.  li\  poglossal  nerve. 
GP,  Glossopharyngeal  nerve 
V.  Facial  nerve. 

S,  Superior  cer>  ical  ganglion  of  the  sympathetic, 
gr,  Ganglion  of  the  root  of  the  vagus. 
/.  Ganglion  of  the  U  unk  of  the  vagus. 
l.  Auricular  branch -of  the   vagus   (Arnold's 

nerve). 
■j.  Phary  ngeal  branch. 

3,  Convergence  of  nerves   to  form  pharyngeal 
plexus. 

4,  Superior  laryngeal  nerve. 
4',  Internal  branch    of   superior   laryngeal 

nerve 
4",  External  branch   of  superior  laryngeal 
nerve. 

5,  Inferior  laryngeal  nerve  (recurrent). 
•V,    Cardiac    branch    of    inferior    laryngeal 

nerve. 
G  G  D,  Cardiac  branches  of  the  vagus, 

7,  Convergence  of  branches  of  vagus  to  form 
cardiac  plexuses. 

8,  Pulmonary  branches. 

9,  (Esophageal  branches. 

10,  Gastric  branches. 

11,  Splenic  branches. 

12,  Hepatic  brandies. 
SA,  Spinal  accessory  nerve. 

id,  Internal  division  of  spinal  accessor]  . 

erf,  External  division  of  spinal  accessory. 

rc,  tIC,  HIC,  IVC,  Cervical  nerves.         ^_^y 


367 


MOTOR  AND    SENSORY  AREAS   AND  TRACTS   OF  THE   INTERNAL  CAPSULE. 

FIG.   169. 


ES   OPEN 

ES  TORN 
MOUTH    OPENS 
HEAO&EYESTURN 
HEAD  TURNS 
TONGUE 
MOUTH    RETR, 
SHOULDER 
ELBOW 
WRIST 
FINGERS, 
THUMB  ' 
TRUNK 
HIP 
ANKLE 
KNEE 
HALLUX 
TOES 


I  C,  I  C,  Internal  Capsule. 

C  N,  Caudate  nucleus. 

L  N,  Lenticular  nucleus. 

N  C,  Nucleus  caudatus. 

O  T,  Optic  thalamus. 

S,  Line  of  sensory  area  internal  capsule. 


368 


the  Facial  nerve  and  irs  connections,  within  the  aqueduct 

OF  FALLOPIUS. 
FIG.   170. 


1,  Fifth  nerve,  with  the  Gasserian  ganglion.  2,  Ophthalmic  division 
of  the  fifth  nerve.  3,  Superior  maxillary  division  of  the  fifth  nerve.  4, 
Lingual  nerve.  5,  Spenopalatine  ganglion.  6,  Otic  ganglion.  7,  Submax- 
illary ganglion.  8,  Facial  nerve  in  the  aqueduct  of  Fallopius.  9,  Great 
superficial  petrosal  nerve.  10,  Small  superficial  petrosal  nerve.  11,  Stape- 
dius branch  of  facial  nerve.  12,  Branch  of  communication  with  pneumogas- 
tric  nerve.  13,  Branch  of  communication  with  glossopharyngeal  nerve. 
14.     Chorda  tympani.      (Dalton's  Physiologv.) 


369 


ORIGIN   AND  CONNECTIONS   OF  THE    GLOSSOPHARYNGEAL,    PNEI   MO- 
GASTRIC  AND   SPINAL   ACCESSORY   NERVES. 

FIG.    171. 


1,  Facial  nerve.  2,  Glossopharyngeal.  3,  Pneumogastric.  4,  Spi- 
nal accessory.  5,  Hypoglossal.  6,  External  (muscular)  branch  of  the 
spinal  accessory.  7,  Superior  laryngeal  branch  of  the  pneumogastric. 
8,  Pharyngeal  plexus.  Laryngeal  plexus  and  upper  cardiac  branches  of 
the  pneumogastric.  10,  Tympanic  plexus,  from  a  branch  of  the  glosso- 
pharyngeal.    (Hirschfield.     From  Dalton.) 


CHAPTER    XXXI. 

THE    VIRILE    OR    GENESIAC    REFLEX    AND    ITS    SYMPTOMATIC    VALUE 
IN    PRACTICE. 


The  pudic  nerve  branches  from  the  lower  portion  of  the 
sacral  plexus,  comes  out  of  the  pelvis  through  the  great 
sacro-ischiatic  foramen  with  the  pudic  artery,  gluteal  and 
sciatic  vessels  and  nerves.  It  then  re-enters  the  pelvis 
and  gives  off  the  inferior  hemorrhoidal  nerve  and  passes 
along  the  outer  aspect  of  the  ischio-rectal  fossa  to  divide 
into  the  perineal  and  dorsalis  penis  nerve.  The  inferior 
hemorrhoidal  nerve  sometimes  comes  directly  from  the  sa- 
cral plexus  and  is  not  then  a  branch  of  the  pudic.  It  is 
distributed  to  the  rectal  sphincter  muscles  and  inferior  pu- 
dendal nerves.  The  largest  branch  of  the  pudic  nerve,  the 
perineal,  dividing  it  into  superficial  cutaneous  and  deeper 
muscle  branches,  sends  some  filaments  to  the  sphincter  and 
levator  ani  muscles,  but  it  goes  chiefly  to  the  perineal  in- 
tegument, the  scrotum,  penis,  labia  and  anus,  communicating 
with  the  hemorrhoidal,  as  already   indicated. 

The  muscular  branches  come  usually  from  the  pudic, 
pass  forward  and  inward  beneath  the  transverse  perinei 
muscle,  its  terminal  filaments  going  off  to  the  transverse 
perinei,  erector  penis,  accelerator  urinae  and  sometimes  to 
the  bulb  of  the  urethra.  The  dorsalis  penis  nerve  is  a  ter- 
minal filament  of  the  pudic,  going  between  layers  of  perineal 

[370] 


371 

fascia,  through  the  suspensory  ligament  of  the  penis  and 
along  its  dorsum  to  its  glans,  branching  to  the  corpus  cav- 
ernosum  and  integument  of  the  dorsalis  penis.  Its  course 
is  similar  in  the  female.  Ranney  and  Holden,  from  whom 
this  anatomical  description  is  mainly  abbreviated,  here  in- 
troduce a  note  from  Hilton  to  the  effect  that  the  integu- 
ment of  the  side  of  the  penis  is  supplied  by  the  perineal 
branch  of  the  inferior  gluteal  nerve  and  from  no  other 
source.  This  probably  explains  why  the  virile  reflex  is  so 
much  more  rapidly  obtained  by  dorsal  than  by  lateral  tap- 
ping of  the  organ  and  by  the  upward  jerk  or  slow  tension 
of  the  foreskin. 

The  pudic  nerve  is  a  nerve  of  sensation  and  motion  of 
the  genitals  and  genital  regions  of  the  body,  the  perineum 
and  integuments,  the  urethra  and  clitoris,  their  mucous 
walls  and  linings,  the  penis  and  scrotum.  It  is  a  sensori- 
motor nerve  of  special,  as  well  as  pain  sense,  the  nerve  of 
the  genesiac  sense,  in  main  part  at  least,  notwithstanding 
the  probable  associate  genesiac  function  of  the  inferior 
gluteal,  inferior  pudendal  and  some  cutaneous  filaments  of 
the  small  sciatic*  1  believe  the  pudic  is  the  nerve  sui 
generis  of  the  virile  or  genesiac  reflex,  especially  in  its  in- 
fra-umbilical areas.  The  pudic  nerve  and  its  close  perineal 
relations  with  the  lesser  sciatic  and  some  of  its  branches 
in  its  distribution  and  peripheral  reflex  sensibilities  and  re- 
lations, defines  the  boundaries  of  the  virile  or  genesiac  re- 
flex areas.  The  virile  or  genesiac  reflex  phenomenon  is  a 
pudic  nerve  area  reflex.  It  is  the  diagnostic  reflex  of  the 
sexual    spinal    cord    sphere  in  the    normally  sexual    individ- 

*lt  gives  motion  to  the  muscles  of  the  perineum  and  ur»*ra,  sensation  to  the  integu- 
ment of  the  perineum,  scrotum,  labium,  penis  and  the  mucous  covering  of  the  clitoris  and 
the  lining  of  the  urethral  canal.  The  friction  made  upon  the  cutaneous  nerves  of  the  ex- 
ternal genitals  creates  a  reflex  act  from  periphery  to  cord,  and  psychic  impression  from 
brain  to  genito-urinary  centers,  causes  genital  congestions,  genital  and  perineal  contraction, 
which  expel  the  seminal  and  Bartoline  secretions,  urine,  etc.,  etc. 


572 

ual,  independently  of  the  erectile  states  of  the  virile  organ 
or  clitorjs.* 

The  pudic    nerve,  through  its    reflex  function,  of  which 

the  virile  or  genesiac  reflex  is  an  important  part,  makes 
possible  erections,  twitchings,  jerkings,  seminal  emissions, 
scrotal  retraction,  etc.  They  are  brought  about  through  its 
influence  and  relations.  Anatomists  and  physiologists  have 
come  near  to  the  discovery  of  the  virile  reflex  before  but 
just  missed  it,  years  ago. 

If  you  suddenly  stretch  the  foreskin  or  grasp  and  pull 
the  glans  penis  toward  the  umbilicus  of  a  virile  individual, 
you  will  discover  a  sensible  downward  jerk  of  the  organ, 
and  if  you  place  one  or  two  fingers  of  the  other  hand  on 
the  dorsum  of  the  member,  you  will  detect,  by  the  sense  of 
touch,  the  downward  retraction,  as  plainly  as  you  may  see 
the  plantar  and  toe  reflexes  after  stroking  your  finger  tips 
across  the  sole  of  the  foot  or  metatorsal  region.  Both  of 
these  reflexes  are  normally  downward.  Or  if,  while  hold- 
ing the  organ  slightly  tense  by  grasping  the  glans  around 
the  corona,  you  jerk  or  pull  the  organ  up  toward  the  umbilicus 
and  slap  the  inside  of  the  thigh  or  sharply  stroke  upward 
with  the  fingertip  the  inguinal  region  over  Poupart's  ligament 
*  and  the  transversalis  abdomis  muscle,  or  if  you  forcibly 
pinch  up  the  perineal  integument  of  the  perineal  scrotum, 
you  will  elicit  the  same  downward  retraction  of  the  virile 
organ;  appreciable  to  sight,  but  more  so  to  touch.  Or  if 
you  suddenly  tap  the  penis  with  the  same  degree  of  force, 
the  organ  being  rendered  slightly  tense,  this  downward  jerk 
may  be  felt,  even  down  to  the  perineal  portion  of  the  organ. 
The  compressor  urethra    seems  to  contract  and  the  bulbous 


*  Certain  fibers  of  the  pudic  nerve  must  be  concerned  in  the  production  of  the  virile 
reflex  that  are  not  concerned  in  the  erection  or  in  bulbo-cavernous  turgescence.  because  this 
reflex  can  be  elicited  without  necessarily  having  marked  swelling  or  erection  of  the  organ, 
though  with  ureat  excitation  both  erection,  vascular  tumescence  and  the  twitch  of  Onanoff 
appear. 


373 

urethra  may  be  seen  sensibly  to  enlarge,  the  dorsal  and  the 
muscular  branches  of  the  pudic  nerve  seem  to  receive  and 
transmit  the  impression  dorsad  and  return  the  peripheral  im- 
pression transmitted  into  motion,  in  a  true  reflex  manner,  in 
which  the  compressor  urethra  and  the  bulbo-cavernosus 
portion  of  the  penis  participates,  when  the  organ  is  erectile. 
Though  this  retraction  may  be  easily  elicited  when  the 
organ  is  not  in  an  erectile  condition. 

Erection  is  secondary,  resulting  from  more  extended 
penile  excitation  and  not  necessary  to  the  display  of  this 
reflex  sign  of  virility,  though  it  may  be  and  usually  is. 

This  is  a  true  penile  reflex,  a  true  penis  jerk,  a  true 
sign  of  virile  intactness. 

The  jerk  is  as  plainly  backward  and  downward  as  the 
knee  jerk  is  upward,  with  a  healthy  spinal  cord.  It  is  not 
an  erection,  but  a  retraction,  like  that  of  the  gullet  reflex,  a 
downward  and  backward  jerk.  There  need  be  no  erection 
accompanying  this  phenomenon  and  usually  is  none,  though 
erection  may  come  on  through  general  pudic  nerve  excita- 
tion. It  is  more  active  in  an  erectile  state  of  the  organ 
and  may  be  less  active  after  a  normal  erection  has 
been  physiologically  exhausted.  It  is  in  no  sense  a 
penis  erection  phenomenon,  thought  absent  when  power 
of  erection  is  absent  or  lost  from  genuine  organic 
impotency,  and  is  feeble  in  some  cases  or  condi- 
tions of  psychic  impotence.  To  determine  its  value  in 
pure  psychic  impotence  and  the  genital  weakness  of  sexual 
neurasthenia,  demands  more  thorough  study  before  abso- 
lutely positive  conclusions  can  be  reached  thereon.  I  have 
seen  it  absent  and  very  feeble  in  persons  who  subsequent- 
ly regained  power,  especially  in  sexual  neurasthenia;  in  the 
prostration  of  typhoid  fever  convalescence  and  two  of  the 
spurious  forms  of  tabes    dorsalis — sexual  exhaustion  tabes — 


374 

DESCRIPTION  OF   FIG.    172    (OPPOSITE   PAGE). 

VL,   IS,   IIS,   IMS,   IVS,  VS,  VIS.— Fifth    lumbar,  and    first,  second,  thir 

sacral  nerves. 
LS,  Lumbo-sacral  cord. 

c,  c,  Posterior  cutaneous  nerves. 

in,  Branches  to  muscles  of  back. 

1,  Branches  to  pyritormis  muscle. 

3,  Muscular  branches  to  obturator  internus. 
II,  llio-inguinal  nerve,  cutaneous,  to  inguinal  region  and  scrotum. 
GC,  Genito-crural  nerve. 

G,  Genital  branch  to  spermatic  cord  or  round  ligament. 
2,  Muscular  branch  to  cremaster. 

C,  Crural  branch,  cutaneous,  to  surface  of  upper  part  of  front  thigh. 
EC,  External  cutaneous. 

P,  Posterior  branch,  cutaneous,  to  upper  and  outer  part  of  thigh. 

A,  Anterior  branch,  cutaneous,  to  front  of  thigh. 

ps,  Muscular  branches  to  psoas  muscle. 
AC.  Anterior  crural  nerve. 

3,  Muscular  branches  to  iliacus. 
3',  Muscular  branches  to  sartorius. 
3",  Muscular  branches  to  pectineus. 
fa,  Branch  to  femoral  artery. 

MC.  Middle  cutaneous  to  front  of  thigh. 

IC,  Internal  cutaneous  to  inner  part  of  thigh. 

LS,  Internal  or  long  saphenous. 

a,  Cutaneous  over  inner  ankle. 

/,  Cutaneous  to  inner  side  of  foot. 

4,  Muscular  branch  to  rectus  femoris. 
4',  Muscular  branch  to  vastus  externus. 
4",  Muscular  branch  to  crureus. 

4  '.  Muscular  branch  to  subcrureus. 
4"",  Muscular  branch  to  vastus  internus. 
Kj,  Branch  to  knee  joint. 
O,  Obturator  nerve. 

///.  Branch  to  hip-joint. 

c',  Communicating  with  branches  of    internal   cutaneous    and    internal 
saphenous. 

5,  Muscular  branch  to  pectineus. 

5',  Muscular  branch  to  obturator  externus. 

6,  Muscular  branch  to  adductor  longus. 
6  .  Muscular  branch  to  gracilis. 

6",  Muscular  branch  to  adductor  brevis. 
6'"  6"",  Muscular  branch  to  adductor  magnus. 
Kj' ,  Branch  to  knee-joint. 
L.  Communicating  branch  to  fifth  lumbar  nerve. 


375 


FIG.   172. 


376 

and  malarial  toxhaemia.  I  have  also  seen  the  knee  jerk 
absent,   and  recovered  from  in  post  malarial  tabes   dorsalis. 

This  reflex  downward  jerk  may  be  elicited  by  friction - 
ing  the  glans  for  awhile  by  rubbing  it  with  a  piece  of  pa- 
pur  (Onanoff's  method)  though  I  have  never  succeeded 
satisfactorily  in  eliciting  it  in  this  way  until  after  the  organ 
got  into  a  state  of  erectile  excitement.  Eliciting  it  in  this 
way  not  only  excites  erection,  but  it  shows  more  as  a  twitch 
modification  of  this  true  virile  reflex,  than  as  the  deliberate 
downward  jerk  1  have  described  as  the  true  virile  reflex. 
This  glans  reflex  friction  method  and  the  resultant  twitch 
is  the  excitation  method  and  the  description  of  M.  Onanoff, 
who  made  his  discovery  about  the  same  time  I  made  mine, 
as  1  learned  when  I  communicated  my  discovery  to  M. 
Brown -Sequard,  as  I  have  stated  in  a  former  communica- 
tion on  this  subject;  but  you  must  note  that  the  Onanoff 
discovery  was  complicated  with  erectile  co-excitation  and 
is  therefore  a  complex  phenomenon,  and  mine  is  not,  and 
is  not  elicited  exclusively  in  Onanoff's  way  of  glans  excita- 
tion, but  chiefly  and  better  in  a  different  and  less  com- 
plicated manner.  Mine  is  obtained  in  various  ways  and  by 
penis  upward  traction  reinforced  by  tapping  or  stroking  or 
pinching  in  any  of  the  genesiac  areas  of  the  body  below 
the  umbilicus.  Onanoff  called  his  discovery  a  bulbo- 
cavernous reflex  twitch,  caused  by  penile  friction  with  a 
a  paper  or  feather,  while  mine  is  a  traction  penile  reflex, 
elicited  when  the  foreskin  over  caput  penis  is  drawn  up- 
ward, as  already  indicated,  if  any  nerve  area  of  the 
inguinal,  perineal  or  genital  region  is  excited,  as  previously 
described,  by  either  upward  penis  traction  or  by  traction 
and  tapping  combined,  or  by  tickling  with  a  straw  or  by 
pinching  or  pricking  certain  areas. 

I  have  seen  it  brought  out  when  drawing  up  the  caput 


377 

penis  to  introduce  the  catheter  into  the  meatus  or  to  get 
into  the  bladder  under  the  pudic  arch. 

This  phenomenon  has  been  in  a  manner  vaguely  and 
indefinitely  known  to  anatomists  and  physiologists  for  sev- 
eral decades  before  1  described  it,  or  before  Onanoff  called 
attention  to  his  similar  phenomenon,  but  it  has  not  before 
been  separated  from  other  penile  phenomena  and  given  the 
distinctive  significance  with  which  1  invest  it.  Thus  Am- 
brose Ranney,  in  1881,  reflecting  anatomical  observation  on 
this  subject  up  to  the  time  of  writing  his  treatise 
of  that  day  on  applied  anatomy  of  the  nervous  system, 
called  attention  to  the  fact  (Applied  Anatomy  of  the  Ner- 
vous System,  1881,  page  469)  that  "in  some  cases  of  frac- 
ture of  the  spine,  in  the  dorsal  region,  where  a  part  of  the 
spina)  marrow  is  left  intact  below  the  seat  of  fracture,  you 
may  be  able  by  repeatedly  pinching  the  skin  of  the  scro- 
tum and  penis,  to  produce  spasmodic  contraction  of  the 
muscles  of  the  perineum  and  urethra  and  often  to  effect 
turgidity  of  the  genital  organ  to  such  a  degree  as  to  make 
it  resemble  an  imperfect  erection  or  priapism."  This  was 
an  approach  to  and  anticipation  of  M.  Onanoff's  bulbo- 
cavernous reflex  discovery. 

It  is  not  uncommon  for  vesical,  as  well  as  urethral,  rec- 
tal and  prostatic  disease  to  produce  sympathetic  manifesta- 
tions in  the  genito-urinary  organs  in  the  form  of  neural- 
gic pains,  involving  involuntary  emissions,  incontinence  of 
urine,  etc.,  etc.  Such  effects  can  only  be  explained  by  the 
distribution  of  the  pudic  nerve  to  the  integument  about  the 
anus  and  I  believe,  to  the  walls  of  the  rectum  also,  which 
allows  reflex  motor  impulses  to  be  sent  from  the  spinal 
cord  in  response  to  rectal  irritation  to  the  genito-urinary 
organs  and  perineal  muscles.  Now  let  us  again  run  briefly 
over  the    subject  of    the    pudic    nerve    and    its  relations  for 


378 

explanation  of  the  modus  operandi  of  this  remarkable  reflex 
and  its  great  value,  which  contributes  further  to  make  the 
pudic  nerve  in  physiological  significance,  next  to  that  of  the 
wonderful  vagus. 

To  recapitulate:  The  virile  reflex  is  lost,  as  you  see,  in 
impotence,  impaired  and  lost  in  time  by  excessive  venery 
and  masturbation,  this  being  Nature's  inexorable  remedy 
and  punishment  for  prolonged  and  senseless  sexual  excesses 
and  the  conservation  of  normal  vitality.  It  is  excited  in  the 
early  stages  and  lost  in  the  later  stages  of  posterior  spinal 
sclerosis,  the  opium  habit  and  extreme  alcoholism.  It  wears 
out  in  the  lascivious  and  bestial,  and  with  extreme  old 
age.  It  is  excited  in  erotic  hyperaesthesi;i,  in  some  stages 
of  hysteria  and  in  various  influences,  normal  and  morbid, 
coming  from  the  rectum,  urethra,  testicles  or  ovaries  and 
by  descending  influences,  normal  or  abnormal,  from  the 
encephalon. 

1  admonish  you  again  to  maintain  the  integrity  of  your 
virile  reflexes,  gentlemen,  in  order  that  you  may  go  through 
life  a  man  among  men  and  women  and  make  a  manly  mark 
upon  your  day  and  generation.  Be  prodigal  of  its  powers 
and  you  will  be  pigmies  in  the  pathway  of  the  giants  you 
might  yourselves  be  in  your  day  and  generation.  The 
world  is  for  the  virile  and  strong.  The  weak  in  the  pudic 
nerve  and  vagus  nerve  areas  of  the  neuraxis  go  to  the 
wall  or  are  trodden  under  by  those  who  better  care  for,  or 
are  better  endowed  in  these  vital  reflex  nerve  centers  and 
in  their  entire  neuraxes. 


CHAPTER  XXXII. 

APHASIA  DEFINED  AND  LOCATED.    APHASIA  PHYSICALLY  AND  PSYCHICALLY 

CONSIDERED.      SOME    OF    ITS    MOST     ESSENTIAL 

PHASES   DISCUSSED. 


An  important  brain  disease,  often  neurovascular  or  rather 
vasoneural  in  origin,  but  sometimes  caused  by  tumor  growths, 
gummata  and  other  adventitia  or  by  temporal  bone  frac- 
ture or  concussion,  involving  a  part  of  the  brain  in  marked 
disorder,  is  aphasia  or  the  alalia  of  Lordat,  the  asemasia  of 
McLane  Hamilton,  the  amnesia,  etc.,  of  other  writers.  This  lo- 
calized brain  disease  has  many    varieties. 

The  form  of  aphasia  first  discovered  was  that  of  lost 
power  of  speech  formation  and  expression.  That  is  the 
power  in  the  mind  to  formulate  ideas  into  speech  language 
once  possessed,  but  lost  by  disease  of  the  speech  center  of 
the  brain.  In  this  disease  there  is  a  paralysis  of  word 
ideation  power  in  the  neurones  of  Broca's  speech  center. 

Bouillaud,  as  early  as  1825,  placed  the  faculty  of  artic- 
ulate speech  in  the  frontal  lobes  of  the  brain  and  so  had 
Gall  before  him  and  the  elder  Dax  located  the  speech  fac- 
ulty in  the  left  side  of  the  frontal  lobes,  while  the  junior 
Dax  located  the  speech  center  in  the  left  antero- lateral 
or  middle  lobe  of  the  brain. 

It  was  reserved  for  Broca  to  still  more  definitely  cir- 
cumscribe it  in  the  posterior  aspect  of  the  third  left  frontal 

[379] 


3S0 

convolution.  .\\.  Broca  had  a  patient  at  BicStre  hospital, 
Paris,  named  Laborgne,  who  on  admission,  appeared  intel- 
ligent, but  could  not  give  his  name  or  answer  any  question 
save  with  a  gesture  and  the  ejaculation  tan  tan  and  an  auto- 
matically familiar  oath  in  French. 

He  had  been  epileptic  from  infancy,  but  had  learned 
the  trade  of  a  last  maker  and  followed  it  till  about  thirty 
wars  of  age,  when  the  loss  of  the  power  of  speech  dis- 
abled him  from  continuing  his  work.  Ten  years  after  admis- 
sion the  power  of  his  right  side  began  to  fail,  and  this  weak- 
ness gradually  extended  to  complete  right  hemiplegia  and 
he  became  bedridden.  There  was  no  facial,  tongue  or  voice 
paralysis    and  only  the  last    act  of  deglutition  was  difficult. 

The  patient  became  affected  with  phlegmonous  erysip- 
elas of  the  right  lower  limb  which,  passing  to  the  head, 
caused  his  death  in  six  days. 

The  post  mortem  revealed  the  dura  and  pia  thickened, 
the  latter  injected,  opaque  and  infiltrated,  but  not  with  pus. 
The  greater  part  of  the  frontal  lobe  of  the  left  hemisphere 
was  soft  and  revealed  a  cavity  the  size  of  a  hen's  egg 
fdled  with  serum  in  the  lower  marginal  convolution  of  the 
temporo-sphenoidal  lobe,  the  convolutions  of  the  island  of 
Reil  and  the  extra-ventricular  nucleus  of  the  corpus 
striatum.  In  the  frontal  lobe  the  inferior  part  of  the  trans- 
verse (ascending)  frontal  convolution  was  destroyed  and 
the  posterior  inferior  half  of  the  second  and  third  frontal 
convolution,  the  greatest  loss  being  in  the  third  frontal. 

Broca  reasoned  from  this  case  that  the  primary  trouble 
was  in  the  third  frontal;  that  this  primary  disease  extended 
to  the  other  convolutions  gradually  and  finally  to  the  island 
of  Reil  and  the  extra-ventricular  nucleus  of  the  corpus 
striatum,  when  hemiplegia  was  complete. 

Broca  had  another  patient  named  Lelong  who,  after  his 


381 

aphasic  seizure,  named  himself  Lelo.  Lelong  had  only  a 
cinque  verbe  vocabulary  consisting  of  oui  for  yes;  non  for 
no;  'tots'  for  trots  (three)  and  toujours  for  always.  His 
fifth  word  was  Lelo,  for  his  name.  Lelong  was  84  years 
old.  He  had  a  fall  on  the  stairs  causing  unconsciousness 
and  apoplectic  symptoms,  but  no  paralysis.  Intelligence  re- 
turned to  him  with  the  coming  back  of  consciousness,  but 
not  the  power  of  speech  beyond  what  we  have  noted.  He 
used  oui,  non  and  Lelo  definitely  and  intelligently.  Tois 
referred  to  any  number,  not  specially  to  three,  and  toujours 
for  every  other  word  idea. 

Lelo  was  an  octogenarian,  who  in  I860,  while  descend- 
ing a  stairway,  fell  unconscious  and  was  treated  for  apo- 
plexy, but  in  a  few  days  he  became  convalescent  without  a 
sign  of  limb  paralysis,  but  with  the  attack  he  had  lost  the 
faculty  of  speech  except  in  the  limited,  crippled  and  bizarre 
manner  above  stated.  His  intelligence  appeared  intact 
through  the  limited  vocabulary  which  he  articulated  with 
difficulty,  but  made  clear  by  an  expressive  facial  mimicry, 
to  those  accustomed  to  be  his  audience. 

This  case,  more  than  any  other  in  M.  Broca's  expe- 
rience, converted  him  from  the  skepticism  with  which  he 
had  challenged  M.  Aubertin  to  the  proof,  not  long  before, 
of  an  anterior  convolution  center  for  speech  lesion,  to  abso- 
lute conviction  and  to  the  definite  area  of  the  third  left 
frontal  convolution,  which  now  bears  the  name  of  Broca's 
speech  center. 

Lelong,  less  than  18  months  after  his  aphasic  attack, 
had  the  misfortune  to  fracture  the  neck  of  his  femur  at  the 
age  of  84  years,  from  which  death  resulted  twelve  days 
after  the  accident.  The  autopsy  of  Lelong  revealed  in  the 
left  hemisphere  a  lesion  limited  to  the  posterior  third  of  the 
second  and  third  frontal  convolutions.     A  small  cavity  filled 


382 

with  serum  was  found  there.  The  right  hemisphere  was 
sound  in  the  corresponding  locality,  the  pia  and  dura  were 
found  normal,  the  arachnoid  held  a  considerable  quantity  of 
serum;  the  .right  hemisphere,  the  cerebellum,  pons  and  me- 
dulla were  healthy.  Only  the  left  hemisphere  showed 
the  lesion  limited  to  the  posterior  third  of  the  second  and 
third  frontal   convolution. 

Remarkable  revelation!  An  old  man  whose  race  on 
earth  is  run,  by  a  fortuitous  accident,  reveals  in  his  death 
a  secret  which  the  ages  have  kept  hidden.  Broca,  a  genius 
of  our  great  profession,  a  son  of  France,  discovers  it  by  the 
light  of  that  same  necroscopic  science  shining  in  another 
age,  which  made  the  great,  the  sublime  Vesalius    immortal. 

These  cases  were  convincing  evidences  to  Broca  of  a 
speech  center  about  the  island  of  Reil.  The  case  of  Lelong, 
especially,  clinched  and  confirmed  his  convictions  of  the  in- 
sular speech  center,  which  now  bears  his  name.  This  em- 
inent and  immortal  clinician  thus  summed  up  the  case  of 
Lelong:  Lelong  understood  all  that  was  said  to  him,  he 
applied  with  discretion  the  four  words  of  his  vocabulary ;  (five 
words,  for  his  name  Lelo  was  one)  ;  his  intelligence  was 
unimpaired;  he  understood  numbers  and  had  neither  lost 
the  general  faculty  of  language  nor  the  power  of  moving 
the  muscles  of  speech  and  sound,  but  only  the  faculty  of 
articulate  language. 

Since  Broca's  discovery,  investigators  have  found  and 
named  many  varieties  of  aphasias  depending  upon  con- 
nection and  lesion  of  other  centers  in  the  brain.  Amnesia 
or  amnesiac  aphasia,  such  as  the  loss  of  the  memory 
of  spoken  words,  agraphia  or  agraphic  aphasia,  the  loss  of 
memory  for  written  words,  sometimes  separately,  and  some- 
times both  together  lost.  Kussmaul,  Tenner  and  especially 
Wernicke,  at  later  dates,   associated  the  hearing  centers  of 


383 

the  temporal  convolutions  with  the  speech  center  of  Broca, 
and  the  term  "word  deafness"  was  born.  Ferrier,  Hughlings 
Jackson,  Broadbent,  Horsely  and  other  later  investigators 
have  contributed  to  extend  the  aphasia  area,  the  center  of 
its^expression,  however,  remaining  where  Broca    located    it. 

fig.  173. 

Charcots  QVx%\uo\P'\aar©.xrv.op  OroX  <x«\& 


I  C,  Ideational  Centre. 
C  A  C,  Common  Auditive  Centre.      C  V  C,  Common  Visual  Centre. 
A  C  W,  Auditive  Centre  of  Words.     V  C  W,  Visual  Centre  of  Words. 
CAL,  Centre  of  Articulate   Lan-     C  W  L,  Centre  of  Written  Lan- 
guage, guage 

The  pen  and  hand  expresses  impression  of  bell  in  writing,  or  in  panto- 
mime or  both.     The  mouth  in  oral  expression  or  aids  in  pantomime. 

The  sight  or  sound  impression  of  a  bell  goes   from  the 


384 

eye  or  ear  to  visual  or  auditory  centers  in  the  brain  and  is 
received  there  and  transmitted  as  a  bell  idea  to  the  speech 
or  language  conception  and  expression  center,  as  the  let- 
ters on  the  bell  diagram  of  Charcot  are  intended  to  show. 
The  next  diagram,  one  of  Langdons,  is  more  elaborate  and 
explicit  and  makes  this  subject  still  plainer.  Nearly  every 
one,  from  Wernicke  to  Broadbent,  Hughlings  Jackson, 
Horsley  and  Langdon,  has  made  some  sort  of  a  diagram  on 
the  blackboard  similar  to  the  one  1  have  hastily  made  with 
the  crayon.  But  1  prefer  not  to  reproduce  my  own,  since 
you  can  have  it  at  every  lecture. 

If  you  will  recall  what  I  have  said  in  previous  prepara- 
tory lectures  on  the  association  of  the  brain,  how  one  cen- 
ter is  brought  into  connection  with  another  center  there,  by 
means  of  projection  and  communicating  fibers  in  the  brain, 
you  can  work  out  the  scheme  of  the  many  possible  varie- 
ties of  aphasia  for  yourself.  Thus  you  would  work  out  au- 
ditory aphasia  or  loss  of  the  memory  of  word  sounds,  vis- 
ual aphasia  or  loss  of  the  memory  of  word  characters. 
Pantomime  memory  loss  would  be  a  variety  of  this  form  of 
aphasia  or  loss  of  the  sign  memory  of  words  and  things. 
There  is  also  an  aphasiac  affection  associated  with  taste, 
smell,  touch  centers,  etc.  As  in  brain  disease,  especially 
some  forms  of  subfrontal  tumor  and  in  epilepsia  and 
syphilis,  patients  have  hyperosmia,  so  they  have  anosmia 
and  other  smell  perversions  from  the  same  cause  and  in 
connection  also  with  aphasia.  There  are  also  taste  and 
smell  expression  failures  in  aphasia. 

But  1  can  not  go  at  length  into  this  subject.  I  can 
give  you  only  the  key  note,  as  it  were,  of  the  aphasia  song. 
When  you  have  leisure  you  may  take  the  key  and  unlock 
the  manifold  treasures  on  the  subject  to  be  found  in  the 
treatise    of  Hughlings    Jackson,    Horsley,    Beevor,    Bastian, 


385 

Bateman,  and    the    monographs    of    Langdon,  Hinchelwood, 
Eskridge,   Ross,  Seguin,  Mills  and  many  others. 

Langdon  has  called  attention  to  the  existence,  as  yet 
unrecorded  except  by  himself,  of  word  anaesthesia,  panto- 
mime blindness  and  pantomime  forgetfulness  in  connection 
with  this  subject,  and  Mills  to  loss  of  object  memory,  as 
distinguished  from  loss  of  name  memories.  Both  of  these 
distinctions  may  interest  you  later.  They  all  come  under  the 
general  name  of  aphasia  ( a-p basis, speech);  absence  of  speech 
memory,  which  includes  any  and  all  of  its  varied  expressions, 
whether  written,  oral,  gestured  or  otherwise  pantomimed.  It 
includes  derangement  of  the  memory  of  speech,  song, 
mimic,  gesture  or  written  character  expression,  one  or  sev- 
eral, but  not  all  of  these  forms  of  expression  and  comprehen- 
sion of  word  ideas  at  the  same  time.  If  all  the  avenues  of 
speech  idea  impression  and  expression  are  destroyed  in  the 
brain,  we  then  have  no  way  of  determining  if  pure  aphasia 
exists.  A  much  more  extensive  brain  area  than  that  con- 
stituting the  group  of  neurones,  making  only  the  speech 
center  of  Broca,  may  be  involved  in  aphasic  disease, 
(Broca's  area  being  the  central  speech  depot,  the  brain's 
hello- girl,  so  to  speak,  of  the  central  phone  office). 

Aphasia  thei\,  in  its  most  comprehensive  sense,  means 
loss  of  sign  or  language  power  construction  (singing,  speak- 
ing, shouting,  gesture,  language,  perceptive  or  constructive), 
expression  in  the  cortex  of  the  brain,  arising  from  disease 
there. 

More  specifically  expressed  aphasia  means  a  loss  of  the 
power  of  written  or  sign  or  sound  perception  or  conception, 
or  expression,  one  or  more  of  these  defects  caused  by  dis- 
ease involving  the  third  left  frontal  convolution  are  of  the 
brain.  More  briefly  yet,  it  is  a  derangement  of  the  word 
or  sign  idea  center  of  the  brain. 


386 

Aphasia  is  usually  caused  by  embolic  instruction  of  the 
left  [piddle  cerebral  artery  or  its  branches  to  the  speech 
center  of  Broca  in  the  third  left  frontal  convolution.  The 
first  branch  being  the  one  chiefly  and  most  usually  in- 
volved in   aphasia. 

Aphasia  may  also  result  from  an  apoplectic  blood  clot, 
a  thrombus,  a  tumor,  an  exudate  or  an  abscess  involving 
the  speech  center,  or  a  wound  of  the  temporal  region  of 
the  skull  may  cause  it,  or  a  pernicious  anaemia  with  or 
without  blood  extravasation.  A  cranial  traumatism  elsewhere 
may  indirectly  implicate  this  important  brain  center.  It  may 
also  result  from  epilepsia  major  or  epilepsia  minor,  or  tem- 
porarily follow  an  attack  of  epilepsia  gravior.  An  attack  of 
hysteria  or  violent  psychic  shock  may  cause  it.  The  person 
in  the  latter  instance  is  then  said  to  have  been  stricken 
dumb. 

Stage  fright  sometimes  develops  it  so  that  one  entirely 
forgets  his  part.  It  may  therefore  be  both  functional  and 
structural  in  its  cause  and  both  transient  and  permanent  in 
its  duration. 

Aphasia  is  strictly  a  focal  disease  of  the  brain,  as 
much  so  as  a  Jacksonian  epilepsy  caused  by  a  tumor, 
pressing  upon  a  single  psychomoter  center.  It  is  a  local 
disease,  as  distinguished  from  a  general  disease  of  the 
brain,  impairing  the  capacity  to  speak,  not  dependent  upon 
any  lesion  in  the  pons  or  medulla  or  of  any  nerve  coming 
out  therefrom. 

The  power  of  speech  is  destroyed  in  coma  and  in 
paralysis  and  in  glosso-labio-laryngeal  paralysis,  etc.,  but 
these  states  are  not  true  aphasia.  To  constitute  true 
aphasia  the  speech  center  must  be  chiefly,  almost  exclusively 
involved.  Aphasia  is  essentially  a  speech  center  disease, 
involving    the  brain  here  and  the  intermediate    neighboring 


387 

avenues  of  word,  sound  or  character  impression  leading  to 
or  going  from  it.  The  keys  or  strings  for  the  performing 
speech-making  neurones  of  the  word  or  sign  center  instru- 
ment in  the  brain,  must  be  out  of  order  to  constitute  a  case 
of  aphasia.  Something  is  wrong  with  the  aphasic's  con- 
nection   with    the    telephone    girl    or    with    the    central    girl 


LANGDON'S   DIAGRAM  OF  APHASIA  AND   ITS  SUBCORTICAL   RELATIONS. 

FIG.  174. 


-^sUcKic        Cortex 


herself.  You  call  up  the  speech  central,  but  get  no  satis- 
factory answer.  Something  is  wrong  there  or  on  the  way 
there  or  from  it.  The  fault  is  at  the  center  or  in  the  con- 
necting neurones. 

Aphasia  should  not  be  confounded  with  aphonia,  or 
the  latter  mistaken  for  the  former.  Aphonia  is  a  loss  of 
voice    from  paralysis    of    the  voice-forming    muscles    of  the 


388 

larynx  and  glottis,  with  the  epiglottis  sometimes  included, 
either  in  their  peripheral  nerves  of  innervation  or  at  the 
origin  in  the  medulla,  of  these  nerves.  Speech  may  also  be 
affected  through  damage  to  the  labial  and  tongue,  as  well 
as  voice  innervation  nerve  areas  and  nerve  tracts,  whose 
source  is  also  in  the  medulla.  Another  set  of  nerve  center 
keys  or  neurones  and  strings  or  nerves,  are  brought  into 
action  in  this  process  of  regulating  the  caliber  and  sounds 
of  the  larynx  or  voice  pipe  of  the  mind  for  communicating 
with  the  outer  world. 

Aphasics  can  therefore  utter  sounds  and  exclamations 
and  they  often  use  a  certain  sound  or  combination  of  sounds 
with  very  different  and  sometimes  very  reverse  meaning 
from  the  ordinary.  Bevin,  as  you  see,  could  only  say  nin- 
nin  for  yes  or  no  or  any  sort  of  affirmation  or  negation. 
One  of  Bastian's  said  bi-bibi,  poy-coy-ba  and  no,  learning 
after  fifteen  months  to  say  yes  and  no  appropriately.  Ham- 
mond reports  an  aphasic  who  said  "what!  certainly — saw 
my  leg  off"  in  answer  to  any  question.  Prof.  Lordat,  de- 
scribing his  own  aphasia,  could  only  use  a  single  exclama- 
tion and  Trousseau,  who  reports  the  case  of  Lordat  at 
length,  records  the  case  of  a  lady  who  on  receiving  a  visi- 
tor would  exclaim,  pig-brute-stupid-fool,  meaning  "Monsieur 
or  Madame,  please  be  seated."  The  impropriety  of  this  un- 
complimentary antithetic  salutation  was  not  recognized  in  its 
enormity  by  the  speaker,  who  supposed  she  was  saying 
the  right  thing,  for  "she  would  smile  sweetly  upon  her 
guest  while  saying  it,  and  in  her  most  charming  manner 
offer  her  visitor  a  chair."  There  is  always  a  lesion  of 
connection  with  the  center  of  word  audition  in  these  cases. 

Another  patient  of  the  brilliant  Trousseau  would,  when 
at  her  devotions,  utter  this  antithetic  sentence,  "Our 
Father    which    art  in  Hell."     There  is    a  sort    of    seeming 


389 

psychic  blindness  to  the  proprieties  in  some  cases.  The 
patient  will  go  on  after  these  outre  and  bizarre  expressions 
as  if  they  were  perfectly  proper.  In  such  cases  there  is 
some  lesion  in  the  auditory  center  relation,  as  I  have  said, 
as  there  is  in  the  visual  relations  when  they  write  the 
wrong  words  or  spell  words  incorrectly.  They  know  how  to 
spell  but  do  not  recognize  the  error.  The  lesion  may  be 
limited  to  auditory  center  connection  when  the  case  is  one 
of  aphasia  only,  or  there  may  be  a  general  lesion  in  the 
understanding.  In  the  latter  case  you  have  insanity  with 
aphasia  or  aphasic  insanity. 

Charcot  had  a  woman  patient  who  said  ta,  and  ta-ta- 
ta-ta,  which  was  all  she  could  say,  a  great  hardship  for  a 
woman,  but  she  meant  everything  by  it. 

A  few  more  illustrations  must  suffice  and  then  we  must 
pass  to  discuss  briefly  another  very  practical  and  important 
aspect  of  aphasia,  viz.:  its  medico-legal  features,  for  aphasia 
is  not  insanity,  it  is  not  apoplexy,  it  is  not  epilepsy, 
though  it  is  sometimes  an  associated  feature  of  these  dis- 
orders of  the  brain.  To  enlighten  the  law  on  the  differ- 
ence is  the  province  of  the  neurologist  and  alienist.  The 
law  needs  much  light  on  the  subject.  Law  may  learn  much 
here  from  the  medical  profession. 

Lesions  of  the  brain  have  been  found,  as  we  have  al- 
ready seen,  in  the  right  insular  area,  in  the  left-handed 
and  in  the  ambidextrous  persons  from  the  time  of  Andral, 
Trousseau  and  the  earlier  clinicians  and  pathologists  to  the 
present  day,  and  where  the  lesion  had  been  a  correspond- 
ing one  on  the  right  side,  it  has  not  been  proven  that  the 
victim  was  not  either  right  or  double-handed  or  both. 
Bateman  cites  three  cases  from  Velpeau,  of  aphasia  con- 
nected with  right  side  lesion,  but  they  do  not  say  whether 
the  patients  were  right  or  left-handed  or  ambidextrous. 
Bateman  also  cites  a  case  from  Velpeau  to  show  how  irri- 
tation of  disease  in  the  left  speech  center  vicinity  may 
cause  irritable  loquacity,  but  I  can  not  take  your  time  to 
recount  it  at   length. 


390 


FIGS.   175  AND  176. 


I3roeao  Center  \»  (Ke  Sijlvian&rtert} 


1 1  - 1 1  i  :    inat 
i,  ironc  do  I'arl  undo  au  lobo  orbitairo.  —  3,  arliro  lr 

ero  ..'mi' 

]>ar  uti  tronc  comimnr9r--^"0,'ari0rc  paridiali.'  ascoodanto. 

1,  trunk  of  middle  cerebral;  2,  artery  to  orbital  lobe;  3,  inferior  frontal 
artery  to  third  left  frontal  or  Broca's  speech  center  convolution;  4,  ascend- 
ing frontal  convolution  arising  from  5,  a  branch  from  the  common  trunk  of 
the  Sylvian;  6,  ascending  parietal  artery.  Other  figures  show  arterial  dis- 
tribution of  Sylvian  branches  to  neighboring  areas  of  the  brain,  including 
ascending  parietal,  frontal  and  temporal  convolutions.  From  Raymond, 
"Clinique"  on  "Disease  of  the  Nervous  System." 

Fig.  1,  2,  3,  F.,  first,  second  and  third  frontal  convolutions;  1,2,3,T., 
first,  second  and  third  temporal;  1  and  2  P;  first  and  second  parietal;  1,  2, 
3,  0,  the  three  occipital  convolutions. 

Cuisse,  thigh;  Jambe,  leg;  Hanche,  hip;  Tronc,  trunk;  Epaule,  shoulder; 
Orteils,  great  toe;  Pied,  foot;  Conde,  elbow:  Poiguet,  wrist;  Doigts,  fin- 
gers; Pouce,  thumb;  Language  center,  muscles  of  the  face  and  mastication. 


391 


FIG.   177. 


r  a. circle  o-c  \\AMe  c\rc\c_) 


CA — Anterior  cerebral,  CAA — Anterior  communicating  cerebral,  CM — 
Middle  cerebral.  CI — International  carotid,  COP — Posterior  communicating 
carotid.  OPO — Posterior  cerebral,  CBS — Superior  cerebral.  CBIA — Anter- 
ior inferior  cerebellar.  AUD — Interior  auditory,  BA-Basillar  artery.  V — 
Varolian.  CHIP — Posterior  inferior  cerebellar.  SPA — Anterior  spinal,  SPP 
P — Posterior  spinal. 


CHAPTER    XXXIII. 

THE    MEDICO-LEGAL    ASPECTS    OF    APHASIA. 
THE  CASE  OF  WM,    T.    BEVIN. 


As  I  have  said,  aphasics  will  often  be  suspected  of  in- 
sanity and  it  may  be  your  professional  duty  some  day,  in 
the  line  of  your  observation,  to  differentiate  between  the 
loss  of  power  of  speech  conception  and  expression,  and  the 
loss  of  mind. 

For  your  further  enlightenment  on  the  subject,  I  here 
give  you  briefly  a  medico-legal  case  in  which  this  question 
was  asked  of  me,  as  a  psychological  expert,  in  a  St.  Louis 
court. 

It  was  the  case  of  Wm.  T.  Bevin,*  an  inquiry  into 
the  question  of  aphasia  or  insanity;  a  hemiplegic  re- 
recovered  with  aphasia  remaining.  Following  is  the  psy- 
chological expert  analysis  and  opinion  rendered  on  the 
witness  stand  in  non-technical  language  and  manner  of 
analysis,  so  far  as  was  practicable,  at  the  October,  1878, 
term  of  Circuit  Court  No.  2. 

The  title  of  this  case  on  the  records  is  Wm.  T.  Bevin 
vs.  Powell. 

On  the  thirteenth  of  March,  1873,  Air.  Wm.  T.  Bevin,  a 

*The  substance  of  this  paper  was  read  before  the  Association  of  Medical  Superin 
tendents  of  Asylums  for  the  Insane,  at  Washington,  D.  C  ,  May  17,  187*,  and  published 
In  the  American  Journal  of  Insanity  for  that  year  under  the  title  of  "  Aphasia  or  Aphasic 
Insanity,  Which  ?  " 

[392] 


393 

builder,  a  few  months  after  the  death  of  his  wife,  was  stricken 
with  right  hemiplegia  and  aphasia.  A  cardiac  valvular 
lesion  preceded  the  paralysis  and  persisted  to  the  time  of 
my  last  examination,  February  7,  1876,  and  to  the  time  of 
his  death,  several  years  after.  His  respirations  were 
twenty-one  per  minute,  lungs  were  healthy,  heart  and 
wrist  pulsations  asynchronous,  the  latter  counting  as  high 
as  one  hundred  and  eight,  and  the  former  sometimes  ten  to 
eighteen  more,  per  minute.  At  this  time  there  was  incom- 
plete paralysis  of  motion  on  the  right  side  and  general 
anaesthesia.  He  was  insensible  to  the  pricking  of  a  pin  in 
both  hands  and  feet.  The  sub-lingual  temperature,  on 
either  side,  was  98°  F.  He  correctly  and  promptly  com- 
prehended oral  signs,  but  tardily  and  imperfectly  understood 
written  ones.  He  soon  recognized  my  name  and  wrote  it 
for  me,  with  his  left  hand.  He  likewise  wrote  his  own 
name  and  the  surname  of  his  attorney  (Mr.  Rainey), 
upon  my  asking  them.  An  H,  written  by  myself,  and  an 
imperfectly  erased  tracing  of  my  surname,  were  on  the 
card  on  which  he  wrote  my  name.  He  first  attempted  to 
attach  "ughes"  to  the  H,  I  had  written,  but  afterwards 
changed  his  mind  and  made  an  H  of  his  own,  which  ac- 
counts for  the  somewhat  disjointed  appearance  of  the  word 
Hughes,  here  following: 


His  tongue  was  clear,  but  he  said  he  always  had  a 
disagreeable  taste  in  his  mouth.  He  either  really  had, 
or  feigned  defective  vision.     When  the  thumb  was  held  up 


394 

before  him,  looking  with  one  eye,  the  other  being  blind - 
folded,  he  would  say  it  was  two,  and  when  the  thumb  and 
little  finger  were  held  up,  he  would  say  there  were  three. 
I  intended  making  an  opthalmoscope  examination,  but  be- 
fore 1  had  opportunity  the  case  came  to  trial,  and  my  tes- 
timony not  being  satisfactory  to  the  family,  1  did  not  offer 
to  examine  him  further.  He  had  defect  of  hearing  in  the 
left  ear,  which  I  thought  feigned  at  the  time,  but  which  I 
later  concluded  was  a  fact,  as  it  was  in  harmony  with  his 
aphasia  and  evidently  resulted  from  the  blood  pressure 
disturbance  in  the  neighborhood  of  the  hearing  center  of 
the  brain,  affecting  the  auditory  conducting  paths  to 
Broca's  center  on  that  side.  He  signed  that  he  could  not 
hear  the  ticking  of  a  watch  half  an  inch  from  his  ear,  yet 
he  distinctly  understood  a  remark  to  him  by  his  sister  in 
quite  an  ordinary  tone,  at  least  twelve  feet  off  from  him, 
at  the  time  1  was  testing  his  hearing  with  the  other  ear. 
None  of  his  family  spoke  to  him  in  a  very  high  tone,  as  is 
customary  when  one  is  deaf.  He  repeated  the  word  uin- 
nin,  accompanied  by  bowing  or  a  nod  of  the  head,  to  sig- 
nify yes  and  by  a  turning  to  left  and  right  to  indicate  no. 
When  1  wrote  W.  T.  Bevin  and  asked  if  that  was  his 
name,  he  shook  his  head  and  taking  the  pencil  wrote 
Wm.  T.  Bevin: 

He  had  three  paralytic  strokes,  and  was  seen  by 
his  relatives  after  each  attack.  He  grew  steadily  better 
in    mind    after  the  first  attack,  notwithstanding  the    subse- 


395 

quent  attacks  which  were  slighter  and  more  transient  than 
the  first  and  displayed  a  singularly  exceptional  knowledge 
of  the  details  of  his  business  affairs  and  signed  with  his  left 
hand  an  intelligent  and  business  agreement  with  regard  to 
some  houses  he  was  building  jointly  with  some  other  par- 
ties, and  in  fulfillment  of  a  promise  and  purpose,  made  and 
entertained  prior  to  his  attack.  He  could  not  write  with 
his  left  hand  before  he  was  stricken.  About  the  same  time 
of,  and  prior  to  the  signing  of  this  deed  of  trust,  he  is  said, 
by  some  of  the  members  of  his  family — principally  his  two 
sisters  and  a  brother-in-law  with  whom  he  lived — to  have 
done  some  things  which  they  swore  they  regarded  as  evi- 
dence of  insanity,  such  as  on  one  or  two  occasions  (none  of 
the  witnesses  testifying  to  more)  bowing  to  pictures  in  the 
parlor,  when  he  knew  members  of  the  family  were  present, 
and  with  a  pleased  but  silly  appearing  smile;  one  side  of 
his  face  being  defective  from  paralysis.  Once  he  is  said 
to  have  wiped  his  nose  on  his  napkin,  and  one  or  twice,  in 
the  early  stage  of  his  paralysis,  they  say  he  spat  on  his 
plate.  Once  he  unbuttoned  his  drawers  when  his  sister 
and  another  lady  were  in  the  room.  It  was  said  that  once, 
after  his  first  stroke  of  paralysis,  he  defecated  in  bed. 
[Once,  he  is  said  to  have  struck  his  mother  with  a  stick, 
though  one  of  his  brothers,  who  swore  there  would  have 
been  no  suit  if  he  had  got  his  three  per  cent,  commission, 
as  promised,  for  taking  his  afflicted  brother's  interest  in  the 
business,  said  he  never  saw  or  heard  of  such  an  affair,  or 
of  unbecoming  conduct  of  any  kind  toward  her. 

Some  or  most  of  these  acts  were  natural  enough  to  his 
paralysis,  as  it  was  also  natural  to  bow  to  the  crucifixion 
and  other  objects  when  asked  to  point  them  out.]  At  this 
time  he  could  not,  the  family  say — all  but  one  brother — 
distinguish  letters  or  tell  if  they  were  upside  down  or  not, 


396 

but  readily  recognized  them  if  their  names  were  called.  As 
early  as  the  first  of  May,  in  1873,  he  could  sit  in  a  chair 
and  get  about  the  room.  In  June  he  appeared  to  one  of 
his  physicians  to  be  silly,  "because  he  smiled  peculiarly" 
and  was  exceedingly  violent  and  irritable  when  the  battery 
was  applied.  To  another  of  his  physicians  he  appeared  de- 
mented, though  he  was  able  to  go  unaccompanied  in  the 
following  November,  a  long  distance,  to  this  physician's 
office,  correctly  select  and  count  his  money  and  pay  his  med- 
ical bill,  and  take  and  put  away  carefully  a  receipt  for  the 
same.  It  was  also  said  that  he  made  grimaces  before  a 
glass  once  or  twice,  and  pulled  out  his  hair,  and  he  ate 
things  when  set  before  him,  that  he  never  ate  before.  He 
handled  his  food  with  his  fingers  (he  could  not  use  a 
knife  and  fork),  and  his  manners  and  tastes  at  table  were 
changed  in  some  other  respects,  he  having  been  formerly 
very  fastidious  and  precise. 

When  he  first  learned  to  write  his  name  he  would 
make  signs  to  visitors  for  a  slate,  write  his  name  for  them, 
and  express  his  pleasure  at  the  accomplishment  by  a  peculiar 
smile.  After  the  description  of  his  property,  mentioned  in 
the  deed  of  trust,  was  read  to  him,  he  pointed  in  the  di- 
rection of  it  and  gave  an  assenting  nod,  pointing  immed- 
iately after  in  the  direction  of  other  property  not  alluded  to 
in  the  document,  and  indicating  his  understanding  that  it 
was  not  included,  by  the  usual  turning  away  of  the  head 
indicative  of  dissent. 

He  was  attended  by  different  physicians  during  the 
first  attack.  The  physician  who  first  saw  him  at  the  time 
of  his  first  seizure  found  him  only  partially  paralyzed  on 
the  right  side,  with  consciousness  still  remaining,  and 
helped  him  home.  In  six  hours  after  this  physician  saw 
him,  he  was  hemiplegic    and  unconscious,  and  so    remained 


397 

for  several  days.  He  commenced  to  improve  in  two  or 
three  weeks.  He  was  then  annoyed  by  movements  about 
the  room  and  exhibited  "not  much,  but  some  signs  of  in- 
telligence in  his  countenance."  He  made  signs  and  efforts 
to  convey  ideas,  and  would  mumble  unintelligibly  in  an- 
swer to  questions  and  had  difficulty  of  deglutition.  He 
never,  at  any  time,  had  delirium,  delusion  or  hallucination. 
He  recognized  Dr.  Mudd  generally  when  he  visited  him. 
One  attending  physician  thought  his  mind  was  impaired, 
because  "there  seemed  to  him  to  be  an  absence  of  power 
of  expression  and  clear  conception  of  subjects."  This  was 
just  after  the  stroke.  This  mental  confusion  was  a  natu- 
ral concomitant  of  the  great  commotio  cerebri  incident  to 
such  a  severe,  extensive  and  sudden  involvement  of  a  cer- 
ebral hemisphere  in  disease,  even  though  that  disease  were 
only  an  embolism  of  the  middle  cerebral  artery.  He  might, 
at  this  stage  even,  have  been  demented,  as  he  was  con- 
sidered to  be,  later,  by  one  of  his  physicians  but  it  could 
not  be  the  real  and  permanent  dementia  which  results  from 
general  degeneration  and  destruction  of  the  cerebral  cortex, 
as  the  improvement  which  soon  began  to  appear  and  all 
the  sequels — his  learning  to  write  with  his  left  hand,  rec- 
ognizing and  designating  friends,  pictures,  etc.,  within  four 
months,  conclusively  proved.  All  the  symptoms  pointed  to 
middle  cerebral  artery  embolic  obstruction. 

When  we  reflect  that  his  hemiplegia  embraced  one-half 
of  his  face  in  paralysis,  simulating  a  Bell's  palsy,  it  is  not 
strange  that  he  should  have  appeared  silly  and  smiled 
peculiarly  in  May.  He  being  irritable  and  violent  when  the 
battery  was  applied  at  that  time,  indicates  only  that  the 
degree  of  paralysis  of  sensation  has  increased  since  then. 
It  is  not  strange  that  he  could  not  distinguish  letters  or 
tell  if  a  book  or  paper  was  upside  down,  confusion  of  vision 


398 

being  the  rule  rather  than  the  exception,  after  hemiplegic 
strokes  and  cerebral  embolism.  The  length  and  position 
of  the  optic  chiasm,  tractus  opticus,  and  of  the  optic 
nerve  within  the  brain,  and  the  manner  in  which  they 
are  placed  and  surrounded  with  blood  vessels,  expose  the 
apparatus  concerned  in  sight  to  great  disturbance  of 
function  from  pressure,  etc.;  for  this  reason  various 
disturbances  of  vision  are  common  in  morbid  condi- 
tions of  the  brain.  This  patient  might  have  been  totally 
blind  from  pressure  consequent  upon  the  cerebra  oedema, 
which  generally  follows  embolic  closure  of  a  vessel  in  other 
parts  of  the  brain  than  the  spot  primarily  implicated  in  the 
embolism,  if  we  take  no  account  of  possible  similar,  sim- 
ultaneous closure  of  other  arteries  of  the  brain. 

In  regard  to  dementia,  which  only  one  of  his  physicians 
asserted  that  he  had  (Dr,  Benkendorf),  it  is  difficult  for  the 
practiced  alienist  and  neurologist,  accustomed  to  observe  the 
phenomena  and  progress  of  this  profound  form  of  mental 
disorder,  to  conceive  how  a  patient  could  have  really  been 
demented  in  June,  in  consequence  of  a  cerebral  vascular 
lesion  grave  enough  to  cause  hemiplegia,  paraplegia,  con- 
fusion of  vision  and  aphasia,  and  yet,  be  so  recovered  by 
the  next  following  November,  as  to  fully  appreciate  the 
services  he  had  received  from  his  physician,  and  go  unac- 
companied to  his  office,  and  settle  in  an  intelligent  manner 
his  bill,  even  though  he  could  not  speak. 

It  was  singular  that  of  all  the  acts  testified  to  by  Bev- 
in's  brother-in-law  and  sisters,  who  were  living  with  him 
and  interested  in  the  success  of  his  suit,  none  of  them 
should  have  been  observed  more  than  once  or  twice  during 
the  whole  time  of  his  affliction.  Many  of  these  acts, 
had  they  occurred  oftener,  would  have  been  explicable  other- 
wise than    on    the  theory  of    insanity,  and    all    of  them,  as 


399 

the  testimony  gives  them  in  this  case,  are  explainable  with- 
out invoking  the  presumption  of  insanity.  1  have  seen  my 
own  little  son  study  the  play  of  his  facial  muscles  in  a  glass, 
and  when  I  was  a  student  of  anatomy  I  did  the  same  thing, 
before  a  mirror,  too. 

The  circumstances  connected  with  the  once  wiping  of 
his  nose  on  the  napkin  or  table-cloth  do  not  appear.  He 
wiped  his  nose  once  or  twice.  It  was  not  shown  that  he  had 
a  pocket-handkerchief,  or  that  he  had  ever  used  his  napkin 
in  lieu  of  a  handkerchief  before  his  affliction,  or  that  he 
did  not  do  it  to  annoy,  rebuke  and  chagrin  those  who, 
should  have  given  him  a  handkerchief. 

[In  the  next  lecture  we  will  conclude  the  record  of  this 
subject.] 


CHAPTER    XXXIV. 


PSYCHOLOGICAL  ANALYSIS   OF  THE   BEVIN   CASE  CONCLUDED. 


None  of  these  acts  indicated  mental  incapacity  on  the 
part  of  Bevin.  Another  medical  gentleman  of  large  practical 
experience  with  the  insane,  no  less  eminent  in  psychiatry  be- 
fore the  courts  and  in  my  own  esteem,  concurred  with  me  in 
the  opinion  that  these  acts  occurring  before  the  signing  of 
the  deed — some  of  them,  as  the  bowing  to  pictures,  etc., 
within  a  month  or  two — did  not  indicate  sufficient  mental 
impairment  to  disqualify  him  for  a  full  appreciation  of  the 
nature,  quality  and  purport   of  the  transaction. 

In  this  case,  1  think,  there  was  mental  impairment  only 
to  the  extent  of  a  crippled  power  of  speech  expression.  There 
•was  impairment  of  executive  (not  reflective)  mental  power  to 
such  a  degree  as  to  incapacitate  the  individual  from  profitably 
engaging  in  the  pursuit  of  his  avocation,  after  he  had  fin- 
ished up  the  business  which  occupied  him  before  his 
affliction.  Mr.  Bevin  seemed  himself  cognizant  of  this  fact, 
and  conducted  himself  after  his  affliction  strictly  in  har- 
mony with  his  surroundings,  till  his  death.  He  learned  to 
write  his  name  with  his  left  hand,  attached  his  signature 
to  an  important  document,  as  it  was  necessary  for  him  to 
do  in  order  to  complete  the  undertaking  he  had  been  en- 
gaged in,  and  after  that  signed  no  more  documents,  nor  at- 
tended in  person    to  any  business,  but  relied  on    the  proxy 

[400] 


401 

of  his  next  friend.  He  knew  he  was  disabled  for  business 
by  his  incapacity  to  properly  express  himself  and  use  his 
mind  as  he  should,  just  as  a  man  with  a  sprain  or  broken 
limb  refrains  from  walking  or  a  business  that  requires 
sprinting,  and  this  knowledge  and  this  fact  and  his  actions 
in  conformity  thereto,  are  proofs  of  his  sanity. 

Let  us  look  at  his  acts  and  see  how  far  they  tend  to 
establish  insanity.  In  the  first  place  they  are  limited  in 
number,  not  a  single  habitual  action  appears  in  his  history 
that  is  at  all  singular.  He  defecated  once  in  bed  at  the 
time  it  is  testified  by  his  family  physician  that  he  was  first 
paralysed.  (This  was  certainly  an  accident  due  to  his 
paralyzed  condition  at  a  time  when  no  one  was  present  to 
assist  him,  and  not  the  result  of  mania.  This  accident  was 
not  repeated.)  No  one  was  present  at  the  time  it  occurred. 
Maniacs  have  often  filthy  habits  long  continued.  Accidental 
occurrences  of  this  kind  are  seldom,  if  ever  observed.  (De- 
ments often  and  habitually  defecate  in  bed  or  in  their  clothes, 
unless  specially  attended  to.)  The  spitting  in  his  plate  once 
or  twice  before  he  had  learned  to  so  co-ordinate  the  damaged 
muscles  of  oral  expulsion,  or  to  adapt  his  position  at  the 
table  to  the  changed  circumstances  of  disease,  was  due  to 
the  facial  paralysis  rather  than  insanity. 

Then  as  to  his  irritability.  Recovering  paralytics  and 
aphasics  are  often  irritable,  and  not  very  reasonable  at  all 
times  when  irritated.  They  can  not  make  their  many  wants 
understood,  and  while  they  understand  themselves  well,  can 
not  well  understand  why  those  about  them  do  not  compre- 
hend their  gestures  and  grimaces  more  readily.  That  he 
should  once  strike  his  mother,  under  such  circumstances, 
does  not  then  appear  as  an  act  of  insanity.  He  was  at 
first  an  irritable,  childish  paralytic,  but  gradually  improved, 
and    never    struck     her    again.       He    did    not    attempt    to 


402 

strike  her  alter  he  had  sufficiently  recovered  to  write  his 
name  with  his  left  hand.  He  never  attempted  to  strike 
anyone  then. 

In  regard  to  the  bowing  to  pictures  which  he  had  not 
seen  since  he  was  stricken  and  carried  to  his  bedroom  a 
helpless  paralytic,  it  would  have  been  more  singular  if  he 
had  not,  when  taken  into  the  parlor,  the  first  time  since 
his  affliction,  have  sought  to  indicate  in  some  way  to  his 
friends  that  he  recognized  the  objects  about  him.  This  act 
showed  an  appreciation  of  his  condition  not  common  to  in- 
sane people,  and  a  desire  to  impress  the  fact  of  his  mental 
improvement  upon  those  about  him,  jusi  as  he  did  the 
frequent  calling  for  paper  or  slate  and  pencil,  writing  his 
name,  and  showing  them  to  visitors  with  manifestations  of 
pleasure  on  his  countenance,  even  though  "his  smile 
looked  silly."  If  he  smiled  at  all  it  must  have  been  a 
silly  looking  smile,  by  reason  of  his  physical  facial  disabil- 
ity. How  could  a  hemiplegic  face  put  on  a  beautiful  or  in- 
telligent looking  smile?  If,  smiling,  or  in  mental  repose, 
his  face  had  even  habitually  shown  the  risus  sardoriicus, 
this  would  not  have  proven  him  mad. 

The  making  of  grimaces  before  the  glass,  and  pulling 
out  his  hair  once  or  twice,  does  not  show  an  insane  motive. 
A  desire  to  discover  to  himself  the  degree  of  muscular  facial 
paralysis  would  not  have  unreasonably  led  him  to  view  him- 
self thus  in  a  mirror,  and  move  the  muscles  of  his  face,  and 
chagrin  at  the  disagreeable  revelations  reflected,  might  lead, 
without  the  concurrence  of  insanity,  to  the  pulling  out  of 
some  hair.  It  does  not  appear  that  he  pulled  out  much  hair, 
or  that  he  often  repeated  the  operation.  I  have  seen  the 
insane  pluck  out  every  hair  of  the  head,  and  repeat  the 
process,  allowing  no  single  hair  to  remain.  It  is  unusual 
for  an  insane  person  to  pull   once  or  twice  at    his  hair  and 


403 

never  repeat  the  operation,  whereas,  the  plucking  of  the 
hair  to  baldness  is  common.  It  is  not  common  for  an  in- 
sane person  to  go  to  the  mirror  for  the  purpose  of  plucking 
out  the  hair,  and  going  to  a  mirror  for  the  purpose  of 
making  grimaces  is  certainly  an  anomaly  among  the  in- 
sane. There  is  too  much  of  rational  motive  in  all  of  these 
acts  for  insanity.  Bevin  desired  to  see  how  he  looked.  And 
this  was  Bevin's  motive.  He  wanted  to  see  how  he  looked, 
and  what  muscles  of  his  face  were,  still  paralyzed.  This  would 
be  only  a  rational  proceeding  on  the  part  of  any  man  con- 
valescing from  a  paralytic  stroke,  which  had  involved,  and 
still  to  some  extent,  implicated  his  face.  It  is  possible  that 
insane  persons,  under  the  dominion  of  a  delusion,  might 
go  before  a  glass  and  pull  at  their  hair,  though  not  usual, 
but  no  delusion  appears  in  this  case,  in  this  connection,  or 
in  any  other  during  the  progress  of  this  case. 

Laying  aside  the  reasonable  presumption  made  by  one 
of  the  attorneys,  that  the  testimony  to  the  outrageous  and 
indecorous  acts  detailed,  was  the  prejudiced  evidence  of  in- 
terested relatives,  enjoying  the  property  placed  in  jeopardy 
by  the  suit,  I  did  not  believe  this  man  to  be  non  compos 
mentis  for  the  transaction  in  which  he  was  concerned,  be- 
cause: 

First.  The  paralysis  alone  was  sufficient  to  account 
for  most  of  his  acts,  his  improvement  and  gradual  recovery 
for  the  remainder;  he  now  being  sound  in  mind  and  able 
to  go  about  with  no  affliction  save  the  aphasia. 

Second.  Because  the  lesion  was  one  primarily  and 
finally  involving  but  a  portion  of  one  hemisphere  of  the 
brain  and  that  mainly  the  speech  area.  Atrophy  or  destruc- 
tion of  a  whole  hemisphere,  especially  if  gradually  brought 
about,  not  even  necessitating  mental  disease,  the  sound 
hemisphere  being   capable  of  vicariously  supplementing  the 


404 


one  diseased ,  in  the  performance  of  the  mental  functions. 
77//'/;/.  The  gray  matter,  even  on  the  affected  side, 
seems  not  to  have  been  greatly  involved  at  any  time,  as 
shown  in  the  absence  of  incoherence,  delirium,  delusion, 
illusion  or  hallucination,  during  the  whole  progress  of  the 
ease,  and  retention  of  memory,  and  ability  to  learn,  for  a 
purpose,  to  write  his  own  name  with  his  left  hand,  in  a 
few  months  after  the  stroke. 

Fourth.  With  the  absence  of  incoherence,  delirium, 
etc.,  there  was  marked  involvement  of  the  face  and  extrem- 
ities, absence  of  muscular  twitchings  in  the  limbs,  and  of 
rigidity  of  the  neck  and  of  other  parts  of  the  body,  which 
usually  accompany  paralytic  lesions  involving  also  more  ex- 
tensive portions  of  the  brain  than  the  Sylvian  fissure  area. 
The  lesion  was  mainly  an  obstruction  of  the  left  middle 
cerebral  artery  at  the  base  of  the  brain,  as  revealed  by  the 
aphasia  and  gradual  coming  on  of  the  paralytic  attack. 

Fifth.  The  nature  of  the  lesion  with  the  part  of  the 
brain  mainly  implicated  in  the  case,  (the  insular  and  Broca 
center)  extending  at  first  up  the  Rolandic  fissure  area,  but 
later  subsiding  so  that  he  could  walk  about  unaided,  is  one 
from  which  persistent  intellectul  aberration  seldom  results. 
Sixth.  I  may  add  since  this  article  originally  ap- 
peared, because  of  the  fact  that  the  primary  lesion  was  a 
rheumatic  embolism. 

Lastly.  For  a  reason  which  some  may  not  deem  of 
any  weight,  namely,  because  that  portion  of  the  brain  which 
has  to  do,  in  all  probability,  with  the  highest  intellection,  are 
the  posterior  lobes  of  the  cerebrum,  and  they  are  not 
nourished  by  the  artery  mainly  concerned  in  the  lesion  be- 
fore us;  "a  conclusion  which,  however  contrary  it  may  be 
to  generally  received  opinion,"  to  use  the  language  of 
Charlton     Bastian,  "has  been  strengthened  by   observations 


405 

made  independently  in  different  directions,  and  by  different 
persons.  It  seems  to  agree,  moreover,  with  clinical  and  pa- 
thological evidence,"*  Dr.  Hughlings  Jackson  and  other  au- 
thorities on  the  subject  of  brain  disease  agreeing  with  him. 
The  above  expert  opinion  and  report  was,  with  a  few 
interlineations,  marked  in  brackets,  given  and  made  in 
1879,  while  Bevin  was  still  living  in  the  healthy  enjoyment 
of  ordinary  intellection,  all  except  the  oral  aphasia. 

The  examination  of  this  case  was  made,  as  you  will  note, 
over  a  quarter  of  a  century  ago,  when  1  had  less  knowledge 
of  aphasia  and  its  many  forms  than  has  been  discovered 
since,  or  than  the  world  knew.  Although  clinically  it  was 
known  to  Benjamin  Rush  and  even  to  Hippocrates,  prob- 
ably, it  was  only  as  late  as  1861  that  those  distinguished 
lights  in  French  medicine,  Messieurs  Gratiolet,  Aubertin 
and  Broca  were  disputing  its  location  as  maintained  by  Bouil- 
laud,  in  the  anterior  lobes,  before  the  Anthropological  Society 
of  Paris,  and  only  a  short  time  before  that  that  the  Daxes 
were  contending  for  a  place  for  it  in  the  fore- brain  frontal 
lobes.  This  memorable  year  of  1861,  memorable  in  France 
for  science,  in  our  Own  country  for  war,  M.  Broca  announced 
his  conversion,  after  a  famous  autopsy  performed  by  him- 
self, to  the  third  frontal  lobe  theory  of  the  younger  Dax, 
and  in  his  conviction  further  circumscribing  the  location  of 
aphasia  to  that  portion  of  the  third  frontal  convolution,  that 
now  bears  his  immortal  name. 

Apropos  of  our  subject,  are  some  observations  on  cerebral 
thermometry  in  aphasia.  Before  the  Paris  Academy  of  Medi- 
icine,  December  30th,  1897,  M.  Broca**  made  the  following 
remarks  upon  local  cerebral  temperatures:  Finally,  in  cere- 
bral affections,  in  aphasia    and  the    paralysis  which  may  be 

*Bastian  on  Paralysis,  from  Brain  Disease,  p.  239. 
**  Gazette  des  Hopitaux,  January  3d,  1880. 


406 

caused  either  by  an  embolus  in  the  Sylvian  artery  or  by  an 
acute  or  chronic  encephalitis  of  the  cerebral  region  which 
surrounds  that  artery,  the  employment  of  a  thermometer 
permits  a  diagnosis  which  the  identity  of  the  symptoms 
would  render  otherwise  almost  impossible.  In  fact,  in 
case  of  em  bol us  of  the  Sylvian  artery,  the  temperature 
which  is  found  lowered  in  the  temporal  region,  is  found,  on 
the  contrary,  quite  notably  increased  at  the  frontal  region, 
and  sometimes  even  also  a  little  at  the  occipital  region. 
This  depends  upon  the  fact,  that  the  re-establishment  of 
the  circulation  in  the  region  which  ceases  to  be  supplied 
by  the  Sylvian  artery  takes  place,  principally,  by  the  anas- 
tomoses of  this  artery  with  the  vessels  which  nourish  the 
anterior  part  of  the  frontal  lobe,  and,  in  proportion,  much 
less  by  the  posterior  anastomoses  of  the  Sylvian. 

In  the  cerebral  softening  by  encephalitis,  we  observe 
something  analogous.  If  the  encephalitis  is  acute,  the  temper- 
ature is  notably  increased  in  all  the  part  affected;  if  the 
encephalitis  is  chronic,  the  differences  are  less  appreciable, 
but  always  of  the  same  kind. 

Encephalitis  is  not  susceptible  generally  of  being 
treated  by  surgical  means.  There  is,  however,  one  case 
where  the  surgeon  may  be  called  upon  to  interfere,  and 
with  great  advantage;  it  is  when  following  a  depression  of 
the  cranium,  some  bony  fragments,  irritating  the  cerebral 
substance,  produces  sometimes  long  after  the  injury,  such 
accidents  as  symptomatic  epilepsy,  etc.  If  then  the  tre- 
phine is  applied,  the  epilepsy  ceases,  once  the  cause  has 
been  removed.  In  such  a  case  we  find  that  the  tempera- 
ture is  elevated  at  the  point  where  it  is  best  to  apply  the 
trephine. 

M.  Broca  used  an  ordinary  thermometer  in  making 
these  researches,  covering  over  the  bulb  with  a  sort  of  hood 
and  waiting  till  the  column  became  stationary. 


CHAPTER  XXXV. 


THE  NEURAL  AND   PSYCHO-NEURAL  ASPECTS   OF  SURGICAL   PRACTICE. 


Surgeons  have  long  known  the  significance  of  knee 
pain  in  hip-joint  disease  through  neural  knee-joint  connec- 
tion. The  importance  of  the  nervous  system  in  its  relation 
to  surgical  diagnosis  had  a  forceful  exemplification  in  the 
case  of  the  lamented  President  Garfield  when  that  persis- 
tent pain  in  his  toe  and  foot,  which  the  distinguished  pa- 
tient complained  of,  was  spoken  of  daily  by  him,  without 
due  notice  being  taken  thereof  by  his  surgeons,  as  refer- 
ring (which  it  did)  to  its  source  of  anatomic  irritation  in 
the  lower  lumbo-sacral  spine,  where  a  vertebral  injury  was 
discovered  post-mortem,  as  having  been  in  the  track  of  the 
assassin's  fatal  bullet.  (Tarsal  branches,  anterior  tibial; 
branch  of  the  external  popliteal;  branch  of  sciatic,  origin 
of  sciatic  (great)  lumbo-sacral  spine,  sacral  plexus,  1st,  2d, 
3d  and  4th  lumbar;  1st,  2d  and  3d  sacral)  That  great 
operation  on  the  nervous  system,  trigeminal  gangliectomy, 
for  which  Spiller  and  Frazier  now  propose  division  of  the 
sensory  root  within  the  cranium  for  tic  doloureux,  as  a 
substitute  for  all  other  operations  on  the  Gasserian  ganglion, 
reminds  us  also  how  closely  in  touch  are  neurology  and 
surgery,  and  the  latter  improved  results,  according  to 
Krause  and  Carson's  records  for  Gasserian  ganglion  excis- 
ion, show  the  conjoined  benefits  of  improved  surgical  technic 
*  L407] 


40S 

and    advanced    neurotherapy.     The   screening    of    the    eye 

alone  Joes  much   more  to  save  the  central     nervous  system 
than  the  external  eye  alone. 

LUMBAR    PUNCTURE    AS    AN    ANAESTHETIC. 

I  have  seen  this  cocain  spinal  injection  substitute  aether 
and  chloroform  obtunding  pain  but  not  consciousness,  both 
in  this  country  and  abroad.  It  is  now  done  from  the  Atlantic 
to  the  Pacific.  I  saw  Winslow  Anderson  and  his  able  col- 
league do  it  in  San  Francisco,  the  patient  looking  on  com- 
placently at  her  own  laparotomy. 

TUFFIER'S  LUMBAR  PUNCTURE   IN  SURGICAL  DIAGNOSIS 
AND   PROGNOSIS. 

Tuffier's  remarkable  lumbar  punctures  have  developed 
much  more  than  therapeutic  significance.  TufFier  himself 
gives  the  operation  diagnostic  significance  in  an  article  in 
the  Bulletin  and  Memoirs  of  the  Society  of  Surgery  last 
year  (No.  27),  suggesting  that  subarachnoid  effusion  of 
blood  mingling  with  the  drawn  cerebro-spinal  lymph  meant 
internal  spinal  fracture.  Here  is  a  diagnostic  procedure  of 
importance  in  obscure  fracture  of  the  vertebrae,  with  pos- 
sible greater  internal  than  external  damage  to  the  integrity 
of  the  spinal  canal  and  the  important  nervous  structures 
and  vital  centers  of  sensation,  motion  and  visceral  function 
which  this  neural  bony  conduit  encases  and  protects. 

Suppose  lumbar  puncture  had  been  in  vogue  in  sur- 
gery at  the  time  of  President  Garfield's  fatal  wounding 
and  employed  in  that  remarkable  case,  i.  e.,  provided  that 
President  Garfield  had  had  for  his  medical  counsel  a  really 
advanced  expert  surgeon,  at  the  beginning  of  his  wounding, 


409 

in  full  rapport  with  the  present  wonderful  resources  of 
neurology  and  surgery  in  diagnosis?  As  it  was,  President 
Garfield  had,  at  the  commencement  of  that  fatal  case,  the 
counsel  of  a  medical  politician,  more  noted  for  his  political 
pull  than  his  surgical  skill,  and  famed  chiefly  as  the  advo- 
cate and  promoter  of  the  now  exploded  Condurango  cancer 
cure,  that  was  then  working  marvels  in  the  daily  press, 
like  the  oil  wells,  some  of  the  gold  mines  and  turf  ex- 
changes of  the  present  day,  and  medical  and  other  fakes 
advertised  in  the  newspapers  of  our  day. 

Lumbar  puncture  for  diagnostic  purposes  is  a  procedure 
for  the  later  stages  of  suspected  spinal  injury,  either  of 
the  meninges,  the  cord  proper,  or  the  bony  canal,  after  giv- 
ing the  effused  blood,  which  is  likely  to  be  small  in  quan- 
tity in  the  beginning,  time  to  accumulate  and  stain  the 
cerebro-spinal  fluid.  In  estimating  the  value  of  this  new 
lumbar  puncture  sign  the  same  principles  would  apply  to  it  as 
elsewhere,  viz.,  the  extent  and  degree  of  hemorrhagic  dis- 
coloration. This  sign  might  also  prove  useful  as  one  ele- 
ment in  the  prognosis  of  the  possible  after  effects  to  the 
cord;  those  sequences  of  concussion  and  molecular 
injury  to  the  cord,  which  cause  so  much  trouble  to 
corporations  and  so  much  real,  as  well  as  litiga- 
tion, distress  to  victims  of  spinal  injury  concussion  and 
cerebro-psychic  shock  and  cause  the  clashing  of  victim  and 
company,  of  neurologist  and  surgeon  in  the  courts. 

LUMBAR  PUNCTURE  AND  NEURO-  OR  CYTO-D1AGNOSIS 
GENERALLY. 
The  lumbar  puncture  needle  promises  to  be  of  as  much 
service  to  the  near  and  new  oncoming  neurology  and 
surgery  as  the  ophthalmoscope,  microscope  or  the  re- 
agents   of    chemistry    have    been    and     now    are.      Neuro- 


410 

surgical  diagnosis  and  prognosis  are  even  now  receiving 
new  impetus  from  them  in  main-  directions.  Recently  be- 
fore the  Medical  Society  of  the  Paris  Hospitals,  many 
wonderful  and  valuable  reports  have  been  made  of  this 
method  of  cyto-diagnosis,  beginning  in  October,  1900,  with 
the  reports  of  Widal  and  Sicard  and  Ravaut,  his  assistants, 
to  whose  work  the  Philadelphia  Medical  Journal  refers 
editorially  with  well -deserved  commendation.  Since  the 
first  communication  of  Widal  a  flood  of  reports  confirming 
the  value  of  this  method  of  cyto-diagnosis  have  appeared 
in  the  literature  of  clinical  neurology  and  general  medicine. 
Monod,  as  this  wide-awake  periodical  notes,  last  year,  in 
Paris,  examined  the'  cerebro-spinal  fluid  of  fifty  nervous 
patients,  finding  leucocytosis  in  locomotor  ataxia  and  general 
paralysis,  finding  nothing  significant  in  alcoholism,  hysteria, 
hemiplegia  or  neuritis.  Chauffard,  Boinet,  Rabaud,  (same 
source  as  above,  viz.,  Bulletins  and  Memoirs  of  the  Medical 
Society  of  the  Paris  Hospitals  for  last  year)  confirmed  the 
findings  of  Widal  and  his  assistants  in  tabes  and  general 
paralysis. 

Many  interesting  showings  were  made  by  examinations 
of  the  fluid  too  lengthy  for  detail  here,  among  them  Nageottes' 
finding  that  in  syphilitic  meningo-myelitis  mononuclear 
leucocytes  predominating  in  the  cerebro-spinal  fluid,  while 
in  the  non-specific  cases  the  majority  of  the  cellular  ele- 
ments are  polynuclear.  The  cerebro-spinal  fluid  was  found 
normal  in  hemiplegia,  brain  tumor,  etc.  In  tubercular 
meningitis,  lumbar  puncture  showed  increasing  lymphocytes 
and  low  osmic  tension,  while  this  cerebro-spinal  fluid  in- 
jected into  rabbits  caused  tuberculosis. 

Here  is  an  important  feature  in  which  surgery  may 
assure  itself  as  to  the  state  of  the  meninges  after  surgical 
operations  and  of   the  existence  or  non-existence  of   tuber- 


411 

culosis,  perhaps  of  the  central  nervous  system,  when  spinal 
puncture  is  used  for  anesthesia. 

The  cerebro-spinal  fluid  after  this  operation  should  in- 
variably be  saved  and  microcytologically  examined.  The 
number  of  leucocytes  should  be  examined  and  counted. 
Laubry  (same  source)  reported  a  case  of  supposed  tu- 
bercular meningitis  disproved  by  this  form  of  cytodiag- 
nosis,  where  autopsy  showed  cerebellar  tumor.  This  work 
is  still  going  on  actively  in  France.  American  surgery 
should  take  it  up,  and  keep  it  up,  until  the  new  mine  of 
diagnostic  wealth  shall  have  been  worked  out.  In  miner's 
parlance  there  is  undoubtedly  ''rich  pay  dirt  here,"  for 
clinical  surgery  as  well  as  for  neurology. 

IDIOTROPHIC  AFFINITIES  AND  REACTIONS  OF  NEURONES. 

The  central  neurones  have  their  special  nutritional  or 
idiotrophic  affinities  appropriating  what  they  need  from  the 
blood  current  for  their  nutrition,  which  means  their  growth, 
life  and  function  and  selecting  their  own  peculiar  manner 
of  response  to  psychic,  peripheral  and  toxic  impression 
as  we  see  in  the  phenomea  of  the  reflexes  of  the  brain  and 
cord,  the  pupil  reflex  and  the  knee  reflex  for  instance,  the 
psycho -motor  movements  of  a  convulsion,  the  opisthotonos 
of  spinal  meningitis  and  tetanus,  the  tremors  of  sclerosis 
and  paralysis  agitans,  the  altered  brain  workings  of  convul- 
sive tic,  of  trigeminal  neuralgia,  etc. 

The  physiology  of  the  five  or  more  senses  is  based  on 
this  peculiar  reaction  of  central  neurones  to  peripheral  or 
central  impression.  They  select  their  own  special  im- 
pressions of  smell,  taste,  touch,  sound,  weight,  etc.  The 
knee  kicks  up,  the  foot  jerks  down,  the  chest  expands,  the 
gullet  contracts  downward,  the  bronchi  and  diaphragm  con- 


412 

tract  so  as  to  throw  air  and  mucus  upward,  as  in  coughing, 
when  their  special  centers  are  set  into  retlex  action  by  per- 
ipheral excitation,  so  we  also  have  the  phenomena  of  fecal 
and  urinary  expulsion,  peristalsis,  etc.,  etc. 

The  irido  or  iris  retlex  is  a  true  idio-retlex.  There  is 
no  other  like  it.  It  contracts  to  light  and  to  certain  drugs 
like  eserin,  and  expands  to  darkness,  atropin,  cocain  and 
other  mydriatics,  ldiotrophic  means,  strictly  speaking,  from 
its  derivation  (when  applied  to  a  neurone  or  group  of  neu- 
rones making  a  nerve  center),  a  peculiarity  of  nutrition  or 
selection  of  its  nutrition.  But  we  extend  its  signification. 
The  selective  affinities  of  certain  centers  of  the  brain  or 
cord  for  anesthetic,  motor  or  sensory  impression  or  what 
has  been  called  the  selective  affinities  of  drugs  which  are 
idiotrophies  of  the  neurones,  is  a  subject  to  thoroughly 
consider,  and  their  psychic  impressibility  in  surgical  practice. 

Barker,  whose  book  is  the  bible  of  modern  American 
neurology,  as  Nissl,  van  Gehuchten,  Lenhossek,  Cajal,  and 
others  are  abroad,  and,  in  fact,  of  the  mundane  neurology 
of  our  day,  for  in  it  are  the  sayings  of  the  wisest  and 
best  sages  and  apostles  of  our  faith,  concerning  the  doc- 
trine of  the  neurones,  following  a  well- merited  defense 
of  Johannes  Mueller,  who  gave  to  neurologic  science  the 
"doctrine  of  the  specific  energies  of  nerves,"  says  "it  has 
been  left  for  the  neurone  doctrine  to  explain,  if  it  can,  why 
it  is  that  on  stimulation  of  the  retina  or  of  the  optic 
nerve,  for  example,  the  response  always  occurs  in  one  and 
the  same  manner;  no  matter  whether  the  stimulation  be 
by  normal  methods  or  by  mechanical  or  electrical  means, 
the  sensation  of  light  or  of  color  alone  is  yielded;  or  how 
it  happens  that  when  a  cold  point  on  the  skin  is  stimu- 
lated, whether  it  be  with  ice,  the  prick  of  a  sharp  tooth 
pick,  an  electric  current,  or  a  piece  of  hot  wire   (cold  point 


413 

paradoxical  reaction  of  von  Frey),  the  sensation  of  cold 
always  results.  The  constancy  of  the  quality  of  the 
reaction,  despite  the  variability  in  the  form  of  the  external 
stimulus,  is  one  of  the  most  puzzling  of  the  phenomena 
with  which  the  neurologist  has  to  deal." 

To  me  this  does  not  seem  so  puzzling  in  view  of  the  idio- 
trophic  properties  of  the  neurone  as  1  here  use  the  term. 
Though  Barker  still  considers  the  question  as  obscure  and 
refers  to  well-known  pathologic  cases  in  which  direct  irri- 
tation of  certain  areas  of  the  cortex  "has  called  forth 
definite  sense  perceptions,  as  evidence  that  these  sense 
perceptions  speak  for  direct  relation  of  these  bodies  to  the 
specific  energies  of  the  sensory  nerves."  The  explanation 
is  in  that  wonderful  individuality  of  the  neurone,  to  which 
1  have  already  referred  as  the  crowning  cap  sheaf  cytolo- 
gical  discovery  of  the  nineteenth  century  making  the  name 
of  Ramon  y  Cajal  immortal.  The  idiotrophic  property  of 
the  neurone  unit  explains  why  "odors,  images  of  colored 
objects,  memories  of  muscular  movements,  and  of  sounds 
have  been  experienced  by  individuals  suffering  from  the 
pressure  of  cysts  and  other  bodies  upon  the  corresponding 
cortical  sense  areas,"  and  why  normal  sensations  reappear 
in  nerve  centers  when  limbs  are  removed,  and  why  memo- 
ries of  impression,  psychic  or  physical,  persist.  We  need 
but  subject  the  matter  to  the  test  of  reason.  It  appears  as 
an  axiomatic  truth  of  the  new  cytology,  that  the  neurone 
has  this  property,  as  the  character  and  proof  of  its  indi- 
viduality as  distinctive  and  individual  as  the  selection  of 
its  own  reconstructive  nutrition;  which  is  as  distinctive 
as  its  chromophile  and  achromatic  properties. 


CHAPTER   XXXVI. 

THE    NUTRITION  AND    CONSERVATION    OF  THE    NEURONES,  OR  NEURO- 
AND   PSYCHO-NEUROTHERAPY   IN   SURGERY. 


The  popular  misconception  of  the  surgeon  is  that  he  is 
only  a  cutter.  This  misconception  extends  often  to  the 
surgeon  himself,  and  it  is  not  always  confined  to  junior 
surgeons,  who  might  be  excused  for  knowing  no  better. 
In  consequence,  there  sometimes  develops  in  the  surgical 
mind  a  flippant  skeptical  treatment  of  the  resources  of 
medicine,  especially  of  the  wonderful  modern  neurotheraphy. 

The  popular  misconception  about  the  neurologist  is  that 
he  is  fitted  to  treat  only  nervousness  and  the  neuroses  of 
hypochrondria,  neurasthenia  and  the  imagination,  and  to 
fool  with  a  lot  of  chronic  maladies  of  the  cerebro-spinal  axis 
and  peripheral  nervous  system,  requiring  more  time  and 
patience  than  the  average  surgeon  has  to  devote  to  them. 
But  1  tell  you  as  a  medical  man  of  once  extensive  surgical 
practice,  that  neurology  and  neuriatry  are  fundamental  in 
medicine  and  surgical  practice,  and  they  cannot  be  longer 
ignored  in  either  clinical  medicine  nor  in  the  most  possibly 
successful  clinical  surgery.  It  is  the  surgeon  who  treats 
the  whole  patient,  neuriatrically  and  psychiatrically  and 
otherwise  therapeutically,  up  to  the  advancing  modern 
standard,  who  will  carry  the  greater  trophies  of  recovery 
in  his  warrior  belt,  as  the  conqueror  of  disease. 

[414] 


415 

There  is  a  psychic  and  neural  and  psycho-neural  anti- 
sepsis, as  well  as,  and  no  less  valuable,  as  affecting  prog- 
nosis, than  the  antisepsis  of  the  vascular  and  absorbent 
systems,  which  have  made  Lister  and  many  of  his  follow- 
ers immortal  and  enabled  modern  surgery  to  invade  and 
rescue  victims  of  disease  from  the  very  grasp  of  death. 
Added  to  Listerism  and  the  dauntless  skill  of  its  world  ap- 
plauded votaries  in  your  illustrious  ranks,  comes  now  mod- 
ern neuro-therapy  that  enables  disease's  prostrate  and  im- 
prisoned victims  to  hold  out  through  judicious  cytological 
reinforcement,  till  the  new  and  conquering  surgery  accom- 
plishes its  saving  work  and  rebuilds  and  restores  the 
assaulted  central  neurones. 

THE   PSYCHIATRIC   FACTOR  IN  SURGERY 

Consists  in  conserving  the  integrity  of  the  psycho-neurones 
by  withholding  from  the  patient  and  avoiding  both  during 
and  after  the  surgical  operation,  everything  that  may  tend 
to  lower  mental  or  physical  vitality.  To  this  end  blunt  an- 
nouncement of  an  operation  intended  and  abrupt  statement 
of  possible  doubtful  prognosis,  the  needless  display  of  the  sur- 
gical tray  and  the  prelude  preparations  and  discussion  of  the 
intended  procedure  by  nurses,  except  under  the  specific,  de- 
tailed directions  of  the  surgeon,  should  be  avoided.* 

The  employment  of  anesthesia  in  our  day  has  saved 
patients    intended    for    the    operating    table    much   psychic 

*The  little  surgeon  who  pompously  displays  his  tray  of  instrument  before  his  tremb- 
ling patient  and  to  his  woeful  wondering  mind  decants  upon  the  operation  he  is  about  to  per- 
form, and  the  chances  of  recovery,  or  displays  a  nonchalant  unfeeling  mien,  acts  unwisely 
and  does  not  increase  his  patient's  chances  of  getting  well  quickly. 

And  the  great  surgeon  who  takes  his  patient  into  the  operating  room  and  places  him 
while  conscious  on  the  table,  himself  with  instruments  in  hand,  while  white  aproned  attend- 
ants gather  around  the  victim,  approaching  with  sponge  and  bottle  and  instruments  and  ap- 
pliances of  the  impending  operative  procedure,  is  not  so  wise  a  surgeon,  and  does  not  so 
fully  consider  the  effect  of  depressing  psychical  influences  as  he  who  chloroforms  the  intend- 
ed subject  of  an  operation  in  another  room  or  in  the  same  room  without  these  depressingly 
suggestive  influences.—  Alienist  and  Neurologist,  Oct.,  1S96. 


416 

shock  they  did  not  escape  in  the  past.  If  to  this  should 
be  added  the  anesthetizing  of  the  patient  in  a  cheerful 
flower  decked,  gratefully  odored  room,  without  any  appear- 
ances of  the  coming  bloody  ordeal,  and  the  patient  wheeled 
into  the  operating  room  while  anesthetically  unconscious, 
psychic  conditions  of  restive  recuperative  central  nerve 
tone  would  be  enhanced. 

PSYCHICAL  DEPRESSION   AND  THE    NEUROPATHIC    DIA- 
THESIS. 

As  a  sound  neuro-surgical  aphorism  I  should  say,  from 
the  standpoint  of  a  broad  experience,  avoid  all  sources  of 
psychic  depression  and  consider  well  the  nervous  system  of 
your  patient  before  and  after  every  operation.  There  are 
some  constitutions  so  neuropathic  and  psychopathically  pre- 
disposed that  the  shock  of  such  an  announcement  would 
precipitate  a  crisis  of  mental  alienation  and  it  were  better 
that  the  proposed  operation  should  be  abandoned  than  in- 
sisted upon  under  such  circumstances,  or  that  the  patient 
should  be  gradually  approached  and  prepared  by  cautious 
speech  and  suitable  precursory  reconstructive  and  tranquil - 
izing  neurological  treatment.  Many  of  the  post- operative 
insanities  and  neuroses  result  from  awakening  into  active 
life  the  psycho- neuropathic  diatheses  and  might  not  result 
in  neurotically  well  prepared  or  psycho- neurotically  well  en- 
dowed nervous  organisms. 

And  these,  gentlemen,  are  the  victories  of  modem  sur- 
gery: A  skilled  technic  never  before  equaled.  Anesthesia, 
general,  peripheral  and  spinal;  antisepsis,  cytotherapy.  And 
the  honors  are  even,  for  anesthesia  and  cytotherapy  are 
ours.  Antisepsis  and  the  new  operative  technic  are  yours. 
Fortunately    for    mankind    these    advances    are    all   in    one 


417 

family  and  that    family   is  one    for    the  weal  of    a  suffering 
world. 

POST-OPERATIVE   INSANITY. 

As  a  suitable  addendum  to  this  chapter,  let  me  here 
quote  one  of  my  editorial  criticisms  from  the  Alienist  and 
Neurologist  of  October,  1901:  A  St.  Louis  surgeon  having 
performed  an  enterorrhaphy  with  acute  mania  without 
sepsis  as  a  sequel  gives  this  as  a  rule  which  he  declares 
has  been  adopted  by  most  surgeons,  viz:  Under  no  circum- 
stances ought  any  insane  woman  to  be  operated  upon  unless 
for  some  distinct  condition  that  is  compromising  life. 

This  is  not  as  a  rule  based  on  clinical  knowledge,  with 
those  who  have  done  their  own  surgery  in  a  hospital  for 
the  insane  or  have  advised  surgical  procedures  on  the  in- 
sane. Psychiatry  looks  at  the  subject  differently.  A  grave 
surgical  disease  preceding  insanity  or  supervening  a 
psychosis  may  be  removed  unless  the  proposal  to  operate 
and  the  preparation  and  operative  procedure  are  in  the  line 
of  and  tend  to  aggravate  the  patient's  delusions.  Rules  of 
therapeutic  procedure  medical,  moral  or  surgical  in  psychia- 
try are  out  of  the  range  of  the  average  surgeon's  clinical 
experience  and  he  should  defer  to  psychiatric  judgment  in 
the  premises  and  not  formulate  rules  purely  from  the  sur- 
geon's standpoint.  The  practical  alienist  might  enlighten 
surgery  in  some  surgical  quarters  where  surgeons  walk  in 
darkness  and  the  darkness  comprehendeth  not. 

1  would  like  to  ask  if  this  is  the  rule  adopted  by  most 
surgeons?  If  so  it  is  not  a  wise  one.  Sources  of  physical 
drain  and  irritation  should  be  removed,  if  practicable,  from 
the  insane  and  nervous  as  well  as  the  sane  and  nervously 
well. 


JIM  22    1928 


